Oral mucosal changes in coeliac patients on a gluten-free diet

Beyond the Gut: A Systematic Review of Oral Manifestations in Celiac Disease

BACKGROUND

Celiac disease (CD) is a chronic immune-mediated gluten-sensitive enteropathy, affecting about 1% of the population. The most common symptoms include diarrhea, abdominal pain, weight loss, and malabsorption. Extra-intestinal symptoms include oral manifestations. This systematic review aims to catalog and characterize oral manifestations in patients with CD.

METHODS

a systematic literature review among different search engines using PICOS criteria has been performed. The studies included used the following criteria: tissues and anatomical structures of the oral cavity in humans, published in English and available in full text. Review articles and papers published before 1990 were excluded.

RESULTS

209 articles were identified in the initial search. In the end, 33 articles met the selection criteria. The information extracted from the articles was classified based on the type of oral manifestation. Recurrent aphthous stomatitis (34.6%), atrophic glossitis and geographic tongue (15.26%), enamel defects (42.47%), delayed dental eruption (47.34%), xerostomia (38.05%), glossodynia (14.38%), and other manifestations including cheilitis, fissured tongue, periodontal diseases, and oral lichen planus were found in the celiac subjects of the studies analyzed. The quality of articles on the topic should be improved; however, oral manifestations in CD patients are widely described in the literature and could help diagnose celiac disease.

Nutrition and oral health in children with recently and previously diagnosed celiac disease

OBJECTIVES

To evaluate the nutritional and oral health status of children with previously diagnosed celiac disease (CD) who follow a gluten-free diet and recently diagnosed CD patients.

MATERIALS AND METHODS

Previously and recently diagnosed groups were formed from children with CD, aged 4 to 15 years. A questionnaire was completed about the children's dental history and nutritional and oral hygiene habits. All the children underwent an oral examination, and dmft-DMFT indices were determined. Dental plaque status, periodontal health, and dental enamel defects were recorded. Oral soft tissues were examined for the presence of lesions. Unstimulated salivary flow rate and pH value were evaluated.

RESULTS

A statistically significant difference was determined between the previously and recently diagnosed patients in terms of toothpaste preference (p=0.003), frequency of going to the dentist (p=0.039), and the types of dental treatment they had received (p=0.001). A statistically significant difference was determined between the previously and recently diagnosed patient groups in terms of dmft values (p=0.005).

CONCLUSIONS

Children with CD should be directed to a pediatric dentist to improve oral and dental health, relieve the symptoms of oral mucosal lesions, be informed about enamel defects, and be encouraged to use gluten-free oral care products.

CLINICAL RELEVANCE

The collaboration of pediatric gastroenterologists and pediatric dentists can prevent the progression of oral symptoms in children with CD and eliminate long-term complications in terms of both oral health and multisystemic problems.

Salivary gland involvement and oral health in patients with coeliac disease

Coeliac disease (CD) is a chronic immune‐mediated enteropathy triggered by ingestion of gluten. The aim of this study was to investigate if the salivary glands as a component of the mucosal immune system are involved in CD, leading to sialadenitis and salivary gland dysfunction and associated oral manifestations. Twenty patients with CD aged 49.2 (SD 15.5 years) and 20 age‐ and gender‐matched healthy controls underwent an interview regarding general and oral health, serological analysis, a clinical oral examination including bitewing radiographs, Candida smear, assessment of salivary mutans streptococci and lactobacilli levels, unstimulated and chewing‐stimulated whole and parotid saliva flow rates, analysis of secretory IgA, and a labial salivary gland biopsy. Xerostomia, mucosal lesions, dry/cracked lips and focal lymphocytic sialadenitis were more prevalent and extensive in patients with CD than in healthy controls. Moreover, the patients had less gingival inflammation and higher whole saliva flow rates than the healthy controls, but did not differ regarding dental health and levels of cariogenic bacteria and Candida. The major salivary gland function appears unaffected, contributing to maintenance of a balanced microbiota and oral health in CD patients. Xerostomia and labial dryness may be related to minor salivary gland inflammation and subsequent impaired mucosal lubrication.

Caries among adult patients with controlled celiac disease: A cross-sectional study

INTRODUCTION

Celiac disease (CD) is one of the most common chronic gastrointestinal disorders in the world. Currently, the literature about the dental profiles of patients with celiac disease is sparse and no studies have reported on the oral conditions and caries status of CD patients in Kuwait.

OBJECTIVE

This study investigated the association between CD and caries experience.

METHODS

Two groups were examined; study and control. The study group consisted of controlled celiac disease patients. The control group consisted of subjects who were matched for age and gender to the study group participants. Both groups received clinical and radiographic examinations of their oral cavity. Parameters recorded for the study purposes were-dental caries index (decayed, missing, and filled teeth), salivary flow rates (stimulated and unstimulated), salivary buffering capacity and Lactobacilli and mutans Streptococci bacterial counts.

RESULTS

Patients with CD had statistically significant fewer missing teeth than the controls. There were no other significant differences. Measured stimulated and unstimulated salivary flow rates and salivary buffering capacity showed no statistical differences. Bacterial counts revealed no significant differences.

CONCLUSION

Adult patients with controlled CD showed fewer missing teeth than their counterparts. Other caries and salivary parameters showed no statistical differences between the two groups.

The difference in symmetry of the enamel defects in celiac disease versus non-celiac pediatric population

Background/purpose

Dental enamel defects are related to celiac disease and the dentists are in a perfect situation to identify and report suspected cases. The aim was to evaluate the symmetry of enamel defects in a pediatric Portuguese population with celiac disease and compare it with healthy controls.

Materials and methods

a case-control study was performed in 80 patients with celiac disease and 80 healthy individuals aged 6-18 years old as controls. Data was collected by a questionnaire and clinical observation. Colour, type, and site of enamel defects were recorded and classified according to Aine criteria. Data analysis was performed, and any p-value <0.05 was considered significant.

Results

Enamel defects were found in 55% of patients with celiac disease and 27.5% in the control individuals (p < 0.001). Grade I of Aine's classification was the most found in both groups, but it was higher in the celiac disease group, not only in the permanent dentition, but also in both dentitions with statistically significant difference (p = 0.002 and p = 0.001 respectively). Grade II was found only in the celiac disease group. It was observed that enamel defects in celiac disease were symmetric and the most affected teeth were the first permanent molars (p = 0.003) and the permanent incisors (p = 0.001).

Conclusion

Symmetric dental enamel defects in population with celiac disease are more predominant than in general population. Therefore, individuals with enamel defects, especially those with symmetric lesions, should be well evaluated and the possibility of having celiac disease in the clinical history must be taken into account.

Dermatitis Herpetiformis: Novel Perspectives

Dermatitis herpetiformis (DH) is an inflammatory disease of the skin, considered the specific cutaneous manifestation of celiac disease (CD). Both DH and CD occur in gluten-sensitive individuals, share the same Human Leukocyte Antigen (HLA) haplotypes (DQ2 and DQ8), and improve following the administration of a gluten-free diet. Moreover, almost all DH patients show typical CD alterations at the small bowel biopsy, ranging from villous atrophy to augmented presence of intraepithelial lymphocytes, as well as the generation of circulating autoantibodies against tissue transglutaminase (tTG). Clinically, DH presents with polymorphic lesions, including papules, vesicles, and small blisters, symmetrically distributed in typical anatomical sites including the extensor aspects of the limbs, the elbows, the sacral regions, and the buttocks. Intense pruritus is almost the rule. However, many atypical presentations of DH have also been reported. Moreover, recent evidence suggested that DH is changing. Firstly, some studies reported a reduced incidence of DH, probably due to early recognition of CD, so that there is not enough time for DH to develop. Moreover, data from Japanese literature highlighted the absence of intestinal involvement as well as of the typical serological markers of CD (i.e., anti-tTG antibodies) in Japanese patients with DH. Similar cases may also occur in Caucasian patients, complicating DH diagnosis. The latter relies on the combination of clinical, histopathologic, and immunopathologic findings. Detecting granular IgA deposits at the dermal-epidermal junction by direct immunofluorescence (DIF) from perilesional skin represents the most specific diagnostic tool. Further, assessing serum titers of autoantibodies against epidermal transglutaminase (eTG), the supposed autoantigen of DH, may also serve as a clue for the diagnosis. However, a study from our group has recently demonstrated that granular IgA deposits may also occur in celiac patients with non-DH inflammatory skin diseases, raising questions about the effective role of eTG IgA autoantibodies in DH and suggesting the need of revising diagnostic criteria, conceivably emphasizing clinical aspects of the disease along with DIF. DH usually responds to the gluten-free diet. Topical clobetasol ointment or dapsone may be also applied to favor rapid disease control. Our review will focus on novel pathogenic insights, controversies, and management aspects of DH.

Dental and oral manifestations of celiac disease

Background

The objective of this study was to evaluate the dental and oral manifestations in patients with celiac disease.

Material and Methods

The sample consisted of 40 patients with the disease and 40 without the disease matched by age in southern Brazil. The CD group included patients previously diagnosed by positive anti-endomysial (IgA) examination and confirmed by small intestine biopsy. The presence of dental enamel defects and dental caries was evaluated by a calibrated researcher according to AINE’s and WHO’s criteria, respectively. The history of recurrent aphthous ulcers and dry mouth was obtained through reporting. For the evaluation of the salivary flow, the saliva samples were obtained through the non-stimulated and stimulated saliva collection method.

Results

There was a significant association between CD and dental enamel defects (OR=2.38, P=0.045) and dry mouth (OR=9.15, P=0.002). No difference was found for the report of recurrent aphthous ulcers and caries experience between the two groups. Patients with CD had normal pattern of unstimulated and stimulated saliva flow rates (0.67 ± 0.38 ml / min and 1.14 ± 0.47 ml / min, respectively). A higher occurrence of dental enamel defects was observed in patients with classic CD (P=0.054). Of the 1,962 permanent teeth, 59 presented dental enamel defects, 71.8% of which were in patients with CD (P=0.001), predominantly in molars (P=0.009).

Conclusions

CD increased the likelihood of dental enamel defects and dry mouth sensation. The oral examination can be an important auxiliary tool for the identification of cases of the disease.

Key words:Celiac disease, oral manifestations, dental enamel hypoplasia.

Clinical evaluation of dental enamel defects and oral findings in coeliac children

Purpose

To examine dental hard and soft tissue changes of coeliac children in order to increase the awareness of the pediatric dentists in prediagnosis of especially undiagnosed coeliac disease.

Materials and methods

Sixty children, 28 (46.7%) boys and 32 (53.3%) girls whose ages were between 6 to 16 years were included in the present study. Thirty children who had undergone endoscopy and diagnosed with the coeliac disease in the Şişli Hamidiye Etfal Hospital, İstanbul, Turkey, formed the study group. Also, thirty children clinically suspected of having the coeliac disease with the same gastrointestinal complaints had undergone endoscopy and proven not coeliac were chosen as the control group. Oral examination involved assessment of dentition and specific and unspecific dental enamel defects. Also, soft tissue lesions, clinical delay of the dental eruption, salivary flow rate, pH, and buffering capacity were examined.

Results

Twenty coeliac patients had enamel defects, however none in the control subjects. In the coeliac group, all enamel defects were diagnosed in permanent teeth and as specific in all children. Grade I dental enamel defects found mainly in the incisors. The clinical delayed eruption was observed in 10 (33.3%) of 30 coeliac children and none of the children in the control group. While the level of DMFT/S numbers and stimulated salivary flow rate were found significantly lower in the coeliac group, pH was found significantly higher.

Conclusion

Oral cavity may be involved in coeliac disease and pediatric dentists can play an important role in the early diagnosis of the coeliac disease.

Cutaneous and Mucosal Manifestations Associated with Celiac Disease

Celiac disease (CD) is an immune-mediated, gluten-induced enteropathy that affects predisposed individuals of all ages. Many patients with CD do not report gastrointestinal symptoms making it difficult to reach an early diagnosis. On the other hand, CD is related to a wide spectrum of extra-intestinal manifestations, with dermatitis herpetiformis (DH) being the best characterized. These associated conditions may be the clue to reaching the diagnosis of CD. Over the last few years, there have been multiple reports of the association between CD and several cutaneous manifestations that may improve with a gluten-free diet (GFD). The presence of some of these skin diseases, even in the absence of gastrointestinal symptoms, should give rise to an appropriate screening method for CD. The aim of this paper is to describe the different cutaneous manifestations that have been associated with CD and the possible mechanisms involved.

Association between developmental defects of enamel and celiac disease: A meta-analysis

OBJECTIVES

Studies have observed the presence of extra-intestinal manifestations of celiac disease (CD), including involvement of the oral cavity, such that developmental defects of enamel (DDE) occur. Thus, the aim of this review was to access the polled prevalence of DDE in individuals with CD, and to establish the strength of the association between these two variables.

METHODS

To carry out the systematic review, four electronic databases and the Grey Literature were searched, complemented by a manual search of reference lists within the selected articles. Two pairs of independent reviewers selected the articles, and perform the data extractions and bias risk assessment Studies evaluating the presence of DDE in individuals with CD as well as in healthy individuals and which performed the DDE diagnosis by direct visualization of tooth enamel changes and the CD diagnosis were included. Meta-analyses were performed using the software R.

RESULTS

Of 557 studies, 45 were selected for review, encompassing 2840 patients. The prevalence of DDE in people with CD was 50% (95% CI 0.44-0.57, I² = 88%). In a general analysis, it was observed that patients with CD had a significantly higher prevalence of enamel defects compared to healthy people (RR: 2.31, 95% CI: 1.71-3.12, I² = 98%). Only developmental defects of enamel diagnosed using Aine's method were associated with the disease (RR: 3.30, 95% CI 2.39-4.56, I² = 75%). In a sensitivity analysis involving the deciduous, mixed and permanent dentitions, only individuals with deciduous dentition were observed to have association with the disease (RR: 2.34, 95% CI 1.25-4.39, I² = 39%).

CONCLUSIONS

Patients with enamel developmental defects should be screened for the possibility of their having celiac disease.

Oral Manifestations in Pediatric Patients with Coeliac Disease - A Review Article

Background:

Coeliac disease is a chronic enteropathy that remains a challenge for the clinician, due to its atypical manifestations and etiopathogenic complexity.

Objective:

This article intends to describe the oral characteristics of Coeliac Disease in children in order to facilitate their management in the dental office.

Methods:

A review of the literature was performed electronically in PubMed (PubMed Central, and MEDLINE) for articles published in English from 2000 to April of 2017. The article is also based on the authors' clinical experience with children with coeliac disease. The searched keywords were “coeliac disease “,”oral manifestations “, “dental enamel defects”, “recurrent aphthous stomatitis” and “oral aphthous ulcers”.

Results:

There are some oral manifestations which are strictly related to coeliac disease: dental enamel defects, recurrent aphthous stomatitis, delayed tooth eruption, multiple caries, angular cheilitis, atrophic glossitis, dry mouth and burning tongue.

Conclusion:

The complete knowledge of the oral manifestations of coeliac disease can trigger an effective change in the quality of life of the patients with this disease.

Diagnosis of Lingual Atrophic Conditions: Associations with Local and Systemic Factors. A Descriptive Review

Atrophic glossitis is a condition characterised by absence of filiform or fungiform papillae on the dorsal surface of the tongue. Consequently, the ordinary texture and appearance of the dorsal tongue, determined by papillary protrusion, turns into a soft and smooth aspect.

Throughout the years, many factors, both local and systemic, have been associated with atrophic glossitis as the tongue is currently considered to be a mirror of general health. Moreover, various tongue conditions were wrongly diagnosed as atrophic glossitis. Oral involvement can conceal underlying systemic conditions and, in this perspective, the role of clinicians is fundamental.

Early recognition of oral signs and symptoms, through a careful examination of oral anatomical structures, plays a crucial role in providing patients with a better prognosis.

Urban legends: recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS) is the most common idiopathic intraoral ulcerative disease in the USA. Aphthae typically occur in apparently healthy individuals, although an association with certain systemic diseases has been reported. Despite the unclear etiopathogenesis, new drug trials are continuously conducted in an attempt to reduce pain and dysfunction. We investigated four controversial topics: (1) Is complex aphthosis a mild form of Behçet's disease (BD)? (2) Is periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome a distinct medical entity? (3) Is RAS associated with other systemic diseases [e.g., celiac disease (CD) and B12 deficiency]? (4) Are there any new RAS treatments? Results from extensive literature searches, including a systematic review of RAS trials, suggested the following: (1) Complex aphthosis is not a mild form of BD in North America or Western Europe; (2) Diagnostic criteria for PFAPA have low specificity and the characteristics of the oral ulcers warrant further studies; (3) Oral ulcers may be associated with CD; however, these ulcers may not be RAS; RAS is rarely associated with B12 deficiency; nevertheless, B12 treatment may be beneficial, via mechanisms that warrant further study; (4) Thirty-three controlled trials published in the past 6 years reported some effectiveness, although potential for bias was high.

Urban legends: recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS) is the most common idiopathic intraoral ulcerative disease in the USA. Aphthae typically occur in apparently healthy individuals, although an association with certain systemic diseases has been reported. Despite the unclear etiopathogenesis, new drug trials are continuously conducted in an attempt to reduce pain and dysfunction. We investigated four controversial topics: (1) Is complex aphthosis a mild form of Behçet's disease (BD)? (2) Is periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome a distinct medical entity? (3) Is RAS associated with other systemic diseases [e.g., celiac disease (CD) and B12 deficiency]? (4) Are there any new RAS treatments? Results from extensive literature searches, including a systematic review of RAS trials, suggested the following: (1) Complex aphthosis is not a mild form of BD in North America or Western Europe; (2) Diagnostic criteria for PFAPA have low specificity and the characteristics of the oral ulcers warrant further studies; (3) Oral ulcers may be associated with CD; however, these ulcers may not be RAS; RAS is rarely associated with B12 deficiency; nevertheless, B12 treatment may be beneficial, via mechanisms that warrant further study; (4) Thirty-three controlled trials published in the past 6 years reported some effectiveness, although potential for bias was high.

Dermatitis herpetiformis. Part I. Epidemiology, pathogenesis, and clinical presentation

Dermatitis herpetiformis (DH) is an autoimmune disease that is linked to gluten sensitivity and has a clear relationship to celiac disease. Both conditions are mediated by the IgA class of autoantibodies and the diagnosis of DH is dependent on detection of granular deposits of IgA in the skin. There is an underlying genetic predisposition to the development of DH but environmental factors are also important. Typically, young adults present with excoriations only, as the severe pruritus effectively destroys any primary lesions. Based upon our experience with DH and a comprehensive literature review, we provide an update of DH epidemiology, pathophysiology, and clinical presentation.

The association between celiac disease, dental enamel defects, and aphthous ulcers in a United States cohort

GOALS AND BACKGROUND

European studies have demonstrated that dental enamel defects and oral aphthae are observed in celiac disease (CD). We investigated this association in a US population.

STUDY

Biopsy proven CD patients and controls were recruited from a private dental practice and from CD support meetings. History of aphthae was taken and dental examination was performed by a single dentist. Teeth were photographed and enamel defects graded according to the Aine classification. A second dentist reviewed all photographs.

RESULTS

Among patients (n=67, mean age 34.8+/-21.6 y) compared with controls (n=69, mean age 28.1+/-15.7 y), there were significantly more enamel defects [51% vs. 30%, P=0.016, odds ratio (OR) 2.4, 95% confidence interval (CI) 1.2-4.8]. This was confined to children (87% vs. 33%, P=0.003, OR 13.3, 95% CI 3.0-58.6), but not adults (32% vs. 29%, P=0.76, OR 1.2, 95% CI 0.5-2.8). This was reflected in defects being observed in those with mixed dentition compared with those with permanent dentition (68.4% vs. 29.6%, P<0.0001). The degree of agreement between the 2 dentists was good (kappa coefficient=0.53, P<0.0001), aphthous ulcers were more frequent in CD than controls (42.4% vs. 23.2%, P=0.02).

CONCLUSIONS

This study supports that CD is highly associated with dental enamel defects in childhood, most likely because of the onset of CD during enamel formation; no such association was found in adults. Our study also supports the association between CD and aphthous ulcer. All physicians should examine the mouth, including the teeth, which may provide an opportunity to diagnose CD. In addition, CD should be added to the differential diagnosis of dental enamel defects and aphthous ulcers.

Orally Based Diagnosis of Celiac Disease: Current Perspectives

Celiac disease (CD) is a lifelong immune-mediated disorder caused by the ingestion of wheat gluten in genetically susceptible persons. Most cases of CD are atypical and remain undiagnosed, which exposes the individuals to the risk of life-threatening complications. Serologic endomysial and tissue transglutaminase antibody tests are used to screen at-risk individuals, although a firm diagnosis requires demonstration of characteristic histopathologic findings in the small-intestinal mucosa. A gluten challenge, with a repeat biopsy to demonstrate recurrence of histopathologic changes in the intestinal mucosa after the re-introduction of gluten, is considered for those persons in whom diagnosis remains in doubt. In this paper, we review studies that evaluated: (1) the possibility of using oral mucosa for the initial diagnosis of CD or for local gluten challenge; and (2) the possibility of using salivary CD-associated antibodies as screening tests. Our review shows that orally based diagnosis of CD is attractive and promising, although additional evaluations with standardized collection and analysis methods are needed. There is some evidence of a dissociation between systemic and oral mucosal immune responses in CD. The hypothesis that gluten could stimulate naïve lymphocytes directly in the oral cavity would have important implications for the understanding, diagnosis, and management of CD.

Oral manifestations of celiac disease

INTRODUCTION

Contrary to early beliefs, celiac disease (CD) is relatively common; however, it still remains underdiagnosed since most cases are atypical, with few or no gastrointestinal symptoms and predominance of extraintestinal manifestations. As a consequence, the diagnosis of the disorder often requires a multidisciplinary approach. Also some oral ailments have been described in celiac patients. In this study, we review the papers that have reported oral manifestations in subjects with CD.

METHODS

A comprehensive literature search was conducted in Medline and Embase databases using appropriate key words. Additional papers were selected by cross-referencing from the retrieved articles.

RESULTS

Dental enamel defects are the oral lesions most closely related to CD. There are conflicting data on the association between CD and recurrent aphthous stomatitis. A correlation of CD with atrophic glossitis has been reported, although robust evidence in support of it is lacking. Patients with CD have caries indexes seemingly lower than healthy individuals, but they may experience delay in tooth eruption. Occurrence of other oral mucosal lesions in CD subjects is likely occasional.

CONCLUSIONS

Patients with systematic dental enamel defects should be screened for CD even in the absence of gastrointestinal symptoms. CD screening tests for patients with oral aphthae or idiopathic atrophic glossitis should be selectively considered during a medical evaluation that focuses on all aspects of the patient's status.

Coeliac disease: oral ulcer prevalence, assessment of risk and association with gluten-free diet in children

AIMS

Oral mucosal lesions may be markers of chronic gastrointestinal disorders, such as those causing malabsorption. Our objectives were to assess the prevalence of recurrent oral aphthous-like ulcers in coeliac disease patients living in the Mediterranean area, and to evaluate the impact of a gluten-free diet.

METHODS

A test group of 269 patients (age range 3-17 years) with coeliac disease confirmed both serologically and histologically was compared with a control group of 575 otherwise clinically healthy subjects for the presence, or a positive history of aphthous-like ulcers. Coeliac disease patients with aphthous-like ulcers were re-evaluated 1-year after starting a gluten-free diet.

RESULTS

Aphthous-like ulcers were found significantly more frequently in coeliac disease, in 22.7% (61/269) of patients with coeliac disease versus 7.1% (41/575) of controls (p=<0.0001; chi-square=41.687; odds ratio=4.3123; 95% confidence interval=2.7664:6.722). Most coeliac disease patients with aphthous-like ulcers and adhering strictly to gluten-free diet (71.7%; 33/46) reported significant improvement on gluten-free diet, with no or reduced episodes of aphthous-like ulcers (p=0.0003; chi-square=13.101; odds ratio=24.67; 95% confidence interval=2.63:231.441).

CONCLUSIONS

The epidemiological association found between coeliac disease and aphthous-like ulcers suggests that recurrent aphthous-like ulcers should be considered a risk indicator for coeliac disease, and that gluten-free diet leads to ulcer amelioration.

Oral pathology in untreated coeliac [corrected] disease

BACKGROUND

Many coeliac disease patients with atypical symptoms remain undiagnosed.

AIM

To examine the frequency of oral lesions in coeliac disease patients and to assess their usefulness in making coeliac disease diagnosis.

PATIENTS AND METHODS

One hundred and ninety-seven coeliac disease patients and 413 controls were recruited and the oral examination was performed.

RESULTS

Forty-six out of 197 coeliac disease patients (23%) were found to have enamel defects vs. 9% in controls (P < 0.0001). Clinical delayed eruption was observed in 26% of the pediatric coeliac disease patients vs. 7% of the controls (P < 0.0001). The prevalence of oral soft tissues lesions was 42% in the coeliac disease patients and 2% in controls (P < 0.0001). Recurrent aphthous stomatitis disappeared in 89% of the patients after 1 year of gluten-free diet. Multi-logistic analysis selected the following variables as the most meaningful in coeliac disease patients: dental enamel defects (OR = 2.652 CI = 1.427-4.926) and soft tissue lesions (OR = 41.667, CI = 18.868-90.909). Artificial Neural Networks methodology showed that oral soft tissue lesions have sensitivity = 42%, specificity = 98% and test accuracy = 83% in coeliac disease diagnosis.

CONCLUSIONS

The overall prevalence of oral soft tissue lesions was higher in coeliac disease patients (42%) than in controls. However, the positive-predictive value of these lesions for coeliac disease diagnosis was low.

Oral mucosa of coeliac disease patients produces antiendomysial and antitransglutaminase antibodies: the diagnostic usefulness of an in vitro culture system

BACKGROUND

Antiendomysial (EmA) and antitransglutaminase (anti-tTG) antibodies are the most specific indirect marker of coeliac disease (CD). It is not known whether the oral mucosa of patients with CD is able to produce these antibodies or not.

AIMS

To evaluate the ability of the oral mucosa of patients with CD to produce antibodies in an in vitro culture system.

PATIENTS AND METHODS

Twenty-eight patients with new diagnosis of CD (15 adults and 13 children) and 14 adult subjects with other diseases (controls) were studied. All underwent oral mucosa biopsy and subsequent EmA and anti-tTG assays on the mucosa culture medium.

RESULTS

Sensitivity and specificity of EmA and anti-tTG assayed in the oral mucosa culture medium for CD diagnosis were 54% and 100% and 57% and 100%, respectively. The CD clinical presentation, such as the presence of oral mucosa lesions, did not influence the results of the EmA and anti-tTG assays in the oral mucosa culture medium. There was an association between positivity of antibodies and greater severity of the oral mucosa lymphocyte infiltration.

CONCLUSION

This study demonstrates that the oral mucosa contributes to EmA and anti-tTG production in untreated patients with CD.

Lack of association between celiac disease and dental enamel hypoplasia in a case-control study from an Italian central region

Background

A close correlation between celiac disease (CD) and oral lesions has been reported. The aim of this case-control study was to assess prevalence of enamel hypoplasia, recurrent aphthous stomatitis (RAS), dermatitis herpetiformis and atrophic glossitis in an Italian cohort of patients with CD.

Methods

Fifty patients with CD and fifty healthy subjects (age range: 3–25 years), matched for age, gender and geographical area, were evaluated by a single trained examiner. Diagnosis of oral diseases was based on typical medical history and clinical features. Histopathological analysis was performed when needed. Adequate univariate statistical analysis was performed.

Results

Enamel hypoplasia was observed in 26% cases vs 16% in controls (p > 0.2; OR = 1.8446; 95% CI = 0.6886: 4.9414). Frequency of RAS in the CD group was significantly higher (36% vs 12%; p = 0.0091; OR = 4.125; 95% CI = 1.4725: 11.552) in CD group than that in controls (36% vs 12%). Four cases of atrophic glossitis and 1 of dermatitis herpetiformis were found in CD patients vs 1 and none, respectively, among controls.

Conclusion

The prevalence of enamel hypoplasia was not higher in the study population than in the control group. RAS was significantly more frequent in patients with CD.

Unusual manifestations of celiac disease

Celiac disease is multifaced autoimmune disorder with several extraintestinal manifestations and connections to other autoimmune diseases and other conditions. The recognition of the complex clinical picture of the disease helps doctors to search and diagnose celiac disease even if the gastrointestinal symptoms are lacking. Individuals at risk for celiac disease should be thoroughly investigated and individuals with unusual manifestations of the disease should be screened actively.

Health-related quality of life in adult coeliac disease in Germany: results of a national survey

OBJECTIVE

No national survey on the present clinical spectrum and health-related quality of life (HRQOL) in people with coeliac disease has been conducted in Germany until now.

METHODS

The German Coeliac Society DZG posted a set of questionnaires (self-developed socio-demographic and medical questionnaire, the Short Form Health Survey, the Hospital Anxiety and Depression Scale and the Giessen Symptom Check List) to 1000/18 355 of their members who were >/=18 years (every 18th member following consecutive postal codes of the membership directory).

RESULTS

Four hundred and forty-six usable questionnaires were returned (diagnosis proven by biopsy; 78% female, median age 45.5 years). The median interval between the first medical examination due to symptoms of coeliac disease and the final diagnosis was 1 year. Ninety-eight percent reported a reduction of initial symptoms, 85% an improvement of HRQOL with a median gain in weight of 8 kg after starting a gluten-free diet (median duration of 6 years). Sixty-seven percent adhered all the time to the dietary regimen and 26% adhered most of the time. The most frequent diseases associated with coeliac disease were osteoporosis (15%), oral aphtae (12%) and dermatitis herpetiformis (9%). Because of the presence of gastrointestinal symptoms 26% of the patients met the modified Rome I criteria for irritable bowel symptom. Compared to representative samples from the German population, coeliac disease patients had higher scores for anxiety , fatigue, dyspeptic and musculoskeletal pain, and a reduced HRQOL in 9/10 scales of the SF-36 (all P<0.001).

CONCLUSION

Despite being on a gluten-free diet German coeliac disease patients suffer from a high burden of general and extra-intestinal symptoms and a reduced HRQOL.

Celiac sprue (the great modern-day imposter)

PURPOSE OF REVIEW

To review the current epidemiological information on celiac disease and the various presentations and associated.

RECENT FINDINGS

Epidemiologic studies reveal celiac disease to be common, occurring in approx. 1% of the population. It is being diagnosed worldwide, even in developing countries. The classic mode of presentation has become less common, with diarrhea or a malabsorption syndrome as the mode of presentation in fewer than 50% of individuals. The other major modes of presentation are iron-deficiency anemia, osteoporosis, screening of family members, or incidentally at endoscopy done for dyspepsia or reflux. Neurological presentations may include peripheral neuropathy or ataxia. Arthritis is commonly found in patients with celiac disease when systematically sought. Patients often have a previous diagnosis of irritable bowel syndrome. Autoimmune diseases occur more frequently (three to ten times more) in those with celiac disease than the general population. However, this increased incidence of autoimmune diseases is not prevented by early diagnosis of celiac disease.

SUMMARY

We will review the various associated diseases/presentations of celiac disease. The heterogeneity of the symptoms can make the diagnosis challenging and certainly the great modern-day imposter.

Doença celíaca: sua relação com a saúde bucal

Doença Celíaca é uma intolerância permanente às proteínas contidas no glúten de alguns cereais, como o trigo, o centeio, a cevada e a aveia. A doença manifesta-se principalmente nos primeiros dois anos de vida, sendo o intestino delgado o principal órgão afetado, com manifestações clínicas de diarréia, vômitos e emagrecimento; porém, o diagnóstico, muitas vezes, é difícil, devido ao grande número de casos atípicos da doença. Nestes casos, os sintomas podem ser numerosos e diversificados, tais como baixa estatura, anemia, osteoporose, hipoplasia do esmalte dentário, além de sintomas próprios do quadro clínico de outras doenças imunológicas que podem associar-se à doença celíaca, tais como diabetes mellitus, dermatite herpertiforme, doenças da tireóide, alergia, estomatite aftosa recorrente, entre outras. Devido a essa associação, os profissionais da saúde procurados pelos pacientes podem não relacionar os sintomas à enteropatia; entretanto, esta, se não tratada, pode trazer várias outras complicações à saúde. O objetivo desta comunicação é demonstrar a importância das manifestações bucais, as quais, quando devidamente observadas, contribuem ao diagnóstico da doença celíaca.

Oral findings in coeliac disease and Sjögren's syndrome

OBJECTIVE

Both coeliac disease (CD) and Sjogren's syndrome (SS) have an autoimmune background and increased risk of oral mucosal and dental abnormalities. Individuals suffering concomitantly from CD and SS could even be at a higher risk.

STUDY DESIGN

Oral mucosal and dental abnormalities were examined in 20 patients with CD + SS (mean age 61 years) and compared with age- and sex-matched controls with either CD or SS.

RESULTS

Oral mucosal changes were most common in SS (80%), followed by CD + SS (65%) and CD (40%). Coeliac-type dental enamel defects were found in 89% in CD + SS and in 88% in CD compared with only 25% in SS (P < 0.001). The median number of teeth was six in the CD + SS, 24 in the CD and 22 in the SS group. The DMF index was higher (P < 0.005) in the CD + SS than in the CD group. CD + SS was characterized by higher salivary flow rate (P < 0.001) and lower inflammatory focus score in the salivary glands (P < 0.01) than SS.

CONCLUSIONS

The co-occurrence of CD and SS should be recognized because of its effects on dental and oral mucosal health. A lower salivary gland inflammatory focus score and higher salivary flow rate in CD + SS than in SS suggests that a gluten-free diet treatment may alleviate autoimmune inflammation.

Amlexanox for the Treatment of Recurrent Aphthous Ulcers

Recurrent aphthous ulcer (RAU) is the most prevalent oral mucosal disease in humans, estimated to affect between 5% and 50% of the general population. The minor manifestation of the condition is the most common and is characterised by small, shallow, round or oval lesions that are surrounded by a raised erythematous halo and are covered by a grey-white pseudomembrane. Appropriate management of patients with this condition is largely symptomatic and should focus on reducing ulcer duration, relieving pain and reducing or preventing ulcer recurrence. Amlexanox is a novel anti-inflammatory and anti-allergic agent that has been evaluated for the treatment of RAU in a series of robust clinical trials. After a 100mg dose of 5% amlexanox topical paste, applied directly to the lesion, the maximum serum concentration of the drug was 120 ng/mL, which was achieved 2.4 hours after application. Steady-state concentrations were achieved within 1 week of starting four times daily dosing and there was no evidence of accumulation. In terms of efficacy, application of 5% amlexanox topical paste was shown to consistently and significantly accelerate complete ulcer healing and the time to resolution of pain across four large efficacy studies. Significantly more patients had completely healed ulcers from day 3 (compared with no treatment) and day 4 (compared with vehicle). Healing was mirrored by an improvement in pain: significantly more patients had complete resolution of pain from day 2 (compared with no treatment) and day 3 (compared with vehicle). Overall, amlexanox was well tolerated, with a low frequency of adverse effects. In the oral application studies, adverse effects that were considered by investigators to be potentially related to the study treatment occurred in 2.4% and 2.1% of 5% amlexanox and vehicle recipients, respectively. These effects were mainly local and were all classed as mild to moderate in severity, with the exception of one case of severe stinging in the vehicle treatment group. Furthermore, the incidence of dermal irritation and sensitisation was very low with amlexanox. These findings suggest that 5% amlexanox topical paste is a useful and well tolerated therapeutic option for the treatment of RAU.

Coeliac disease

Coeliac disease is a genetically-determined chronic inflammatory intestinal disease induced by an environmental precipitant, gluten. Patients with the disease might have mainly non-gastrointestinal symptoms, and as a result patients present to various medical practitioners. Epidemiological studies have shown that coeliac disease is very common and affects about one in 250 people. The disease is associated with an increased rate of osteoporosis, infertility, autoimmune diseases, and malignant disease, especially lymphomas. The mechanism of the intestinal immune-mediated response is not completely clear, but involves an HLA-DQ2 or HLA-DQ8 restricted T-cell immune reaction in the lamina propria as well as an immune reaction in the intestinal epithelium. An important component of the disease is the intraepithelial lymphocyte that might become clonally expanded in refractory sprue and enteropathy-associated T-cell lymphoma. Study of the mechanism of the immune response in coeliac disease could provide insight into the mechanism of inflammatory and autoimmune responses and lead to innovations in treatment.

Celiac disease and recurrent aphthous stomatitis: a report and review of the literature

Celiac disease (CD) is a condition related to the small intestine's intolerance to gluten. The diagnosis of CD can be difficult, especially because patients may exhibit a wide spectrum of signs and symptoms. It is important to identify this disease process early because affected individuals have an increased risk for developing lymphoma of the gut. Our objective was to evaluate whether patients with CD have a significantly higher prevalence of recurrent aphthous stomatitis compared with the general population, as some investigators have speculated. Therefore, we screened 61 patients with diagnosed CD for the presence of, or a positive history of, aphthous ulcerations. We then statistically compared this data with a randomly selected control population, matched for age and gender, but without CD. Our results demonstrated no significant differences between groups for age, gender, or prevalence of recurrent aphthous stomatitis.

Characteristics of adult celiac disease in the USA: results of a national survey

OBJECTIVE

The clinical spectrum of adults with celiac disease in the United States, where the disease is considered rare, is not known. We sought this information by distributing a survey.

METHODS

A questionnaire was distributed by way of a celiac newsletter, directly to celiac support groups, and through the Internet.

RESULTS

Respondents (1,612) were from all United States except one. Seventy-five percent (1,138) were biopsy proven. Women predominated (2.9:1). The majority of respondents were diagnosed in their fourth to sixth decades. Symptoms were present a mean of 11 yr before diagnosis. Diarrhea was present in 85%. Diagnosis was considered prompt by only 52% and 31% had consulted two or more gastroenterologists. Improved quality of life after diagnosis was reported by 77%. Those diagnosed at age > or = 60 yr also reported improved quality of life. Five respondents had small intestinal malignancies (carcinoma 2, lymphoma 3) accounting for a relative risk of 300 (60-876) for the development of lymphoma and 67 (7-240) for adenocarcinoma.

CONCLUSIONS

Patients with celiac disease in the United States have a long duration of symptoms and consider their diagnosis delayed. Improved quality of life after diagnosis is common. An increased risk of developing small intestine malignancies is present.

Increase in T-cell subsets of oral mucosa: a late immune response in patients with treated coeliac disease?

BACKGROUND AND AIMS

In coeliac disease, the gut involvement is gluten-dependent. Following the introduction of a gluten-free diet, inflammatory cell infiltration decreases in the small intestinal mucosa. Our hypothesis was that the oral mucosa might mirror the changes found in coeliac disease similarly to the mucosa of the small intestine. Thus, the number of inflammatory cells in the oral mucosa would decrease in patients with coeliac disease on a gluten-free diet.

METHODS

The distribution CD45RO+ and CD3(+) T cells, T-cell subpopulations (CD4(+), CD8(+), T-cell receptor (TCR)alpha beta+ and TCR gamma delta+ cells) and HLA DR expression were studied in the buccal mucosa of 15 untreated and 44 gluten-free diet treated coeliac disease patients, and of 19 controls. All 15 patients with untreated coeliac disease were immunglobulin (Ig)A endomysial antibody positive and all 44 patients on gluten-free diet except one were endomysial antibody negative, as were all control subjects.

RESULTS

Untreated coeliac disease patients did not differ from controls in the densities of CD45RO+ cells, CD3(+) cells or of T-cell subsets. In contrast, in treated coeliac disease patients, a significant increase in the numbers of mast cells, CD3(+) and CD4(+) lymphocytes was found in the lamina propria of oral mucosa as compared with patients with untreated coeliac disease and controls. The increase in CD3(+) T cells was in part owing to an increase in lymphocytes expressing no TCR. No differences were found in the expression of human leucocyte antigen (HLA) DR in the epithelium or in the lamina propria in the patient groups studied or in the controls. In treated coeliac disease patients only a few TCR gamma delta+ T cells were found intraepithelially and in the lamina propria, but these cells were not detected in the lamina propria of oral mucosa of patients with untreated coeliac disease or in the controls.

CONCLUSIONS

The infiltration of T cells into oral mucosa was increased in treated coeliac disease patients in spite of adherence to a gluten-free diet. Because the CD3(+) T cell count was higher than those of the TCR alpha beta+ and TCR gamma delta+ T cells, there must be other cells involved, probably natural killer (NK) cells. The increase in T-cell subsets in the treated coeliac disease patients seems not to result from poor dietary compliance, but might occur as a late immune response in coeliac disease and reflect chronic immunologic stimulation followed by regeneration of memory T cells.

Changes in whole saliva in patients with coeliac disease

Many systemic diseases impair salivary flow rate and composition and therefore incite oral pathological processes. This study analyses the composition of whole saliva in patients with diagnosed coeliac disease (CD) and in healthy controls, and monitors possible changes in saliva composition after a short oral gluten challenge. Paraffin-stimulated whole saliva was collected from 128 CD patients and 55 healthy controls. In a separate study, paraffin-stimulated whole saliva samples were collected from 33 CD patients and 10 controls both before and 24 h after an oral mucosal and submucosal gluten challenge. No difference in saliva flow rate was observed, but total protein (P</=0.001), albumin (P</=0.001), IgA (P</=0.01) and IgG (P</=0.001) concentrations, as well as salivary peroxidase (P</=0.001) and myeloperoxidase (P</=0.001) activities, were significantly higher in CD patients than in healthy controls. The relative amounts of secreted proteins (mg/mg), e.g. amylase (P</=0. 001), total IgA (P</=0.005) and IgM (P</=0.001) were significantly lower in CD patients than in healthy controls. In CD patients, gluten challenge resulted in a decrease in myeloperoxidase (P</=0. 005) activity, IgA (P</=0.001) and IgM (P</=0.005) concentrations and the relative amounts of secreted IgA (P</=0.001). In healthy individuals, however, gluten challenge caused a decrease in total and relative amylase activity (P</=0.005; P</=0.001) and total IgM (P</=0.005) concentration. It is concluded that CD patients, following a strict gluten-free diet, secrete lower relative amounts of amylase, IgA and IgM into paraffin-stimulated whole saliva than do healthy controls.

Local challenge of oral mucosa with gliadin in patients with coeliac disease

In coeliac disease, gluten-containing diet challenges over many years are sometimes required for diagnosis, especially if the initial diagnosis was equivocal. The rectal gluten challenge has been proposed to simplify coeliac disease diagnosis. We were interested in studying whether the oral mucosa could be used for local challenge with gliadin as an aid in finalizing the diagnosis of coeliac disease. The study groups consisted of 37 treated coeliac disease patients and 10 controls. The challenges on the oral mucosa were performed either supramucosally with gliadin powder (coeliac disease patients) or by submucosal injection of dissolved gliadin (10 microg/ml) (coeliac disease patients and controls). A control challenge with submucosal gliadin solvent was made in the coeliac disease patients. B and T cells, mast cells and T cell subsets were counted and HLA-DR expression was determined. Biopsies were taken from each provoked area 24 h post-challenge. A significant increase in the number of CD4+ lymphocytes in the lamina propria (observed in 27/37 patients), but a decrease in the number of mast cells was observed in treated coeliac disease patients after submucosal challenge with gliadin. Following supramucosal challenge with gliadin the counts of intraepithelial CD4+ (in 25/37 patients) and CD8+ T cells (in 27/37 patients) increased significantly and the number of CD4+ T cells in the lamina propria was also significantly increased. Control subjects were tested by submucosal gliadin challenge and no significant changes in the number of cells were observed. HLA-DR expression did not show increased positivity in coeliac disease patients on submucosal challenge. For the first time the oral mucosa has been used for immunological testing and shown to react to gliadin challenge in coeliac disease patients. Recruitment of T cells upon submucosal gliadin challenge occurred towards the lamina propria, whereas it occurred towards the epithelium in supramucosal gliadin challenge. The numbers of T cells increased in the lamina propria after submucosal challenge. The results suggest that local oral challenge with gliadin may be used as a diagnostic method in coeliac disease; however, further studies in untreated coeliac disease patients are needed to evaluate the usefulness of this method.

Salivary antigliadin and antiendomysium antibodies in coeliac disease

The definitive diagnosis of coeliac disease is based on typical changes in the small intestine biopsy specimens. To screen individuals for coeliac disease serum IgA and IgG antigliadin (AGA), IgA antireticulin (ARA) and IgA antiendomysium (EmA) antibodies are used. The aim of this study was to investigate whether these antibodies can also be detected in saliva as diagnostic markers of coeliac disease. The study population comprised 30 patients with coeliac disease treated with a gluten-free diet, 14 patients with untreated coeliac disease and 13 healthy control subjects. Sera and saliva were tested simultaneously for the presence of IgA and IgG AGA and IgA EmA. None of patients studied had a selective IgA deficiency. There was no significant difference in salivary IgA AGA levels between the three groups tested and there was no correlation between the individual serum and salivary values of IgA AGA. Salivary IgG AGA levels were very low or undetectable. Serum IgA AGA showed a low sensitivity (36.4%) to detect an untreated patient with coeliac disease. All salivary samples, regardless of the study group were negative for IgA EmA. Serum IgA EmAs were universally detected in the sera of patients with newly diagnosed coeliac disease and also in the sera of five of 30 patients with treated coeliac disease. No IgA EmA was detected in the sera of controls. None of the patients studied had a selective IgA deficiency either. Serum IgA EmA is the most sensitive, and IgA and IgG AGA are good indicators for coeliac disease, but salivary IgA or IgG AGA and salivary IgA EmA are not helpful for the diagnosis or follow-up of coeliac disease patients.