Celiac disease

Overview

Board takeaway: Protect defective enamel and refer suspected celiac disease for testing before a gluten-free diet is started.

An immune enteropathy triggered by gluten. Symmetric enamel defects or recurrent aphthae may prompt medical evaluation even without gastrointestinal symptoms; neither finding alone diagnoses celiac disease.

How does Celiac disease affect dental management?

• Test before diet change: Refer to the physician for serology while the patient is still eating gluten; starting a gluten-free diet before testing can produce a false-negative result.
• Product ingredients: Verify ingredients when a product may be swallowed; use gluten-free alternatives when indicated
• Protect enamel: Restore or protect hypoplastic enamel; fluoride varnish

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Symmetric enamel defects and recurrent aphthae prompt assessment rather than establish celiac disease. Physician-directed testing should occur while the child is still eating gluten; IgA deficiency affects test choice.

Exam pearl

What is Celiac disease?

A chronic immune-mediated disorder in which dietary gluten triggers injury to the small-intestinal lining in genetically susceptible people, impairing nutrient absorption.

What are the main systemic features of Celiac disease?

• Mechanism: Gluten triggers immune-mediated small intestinal damage in genetically susceptible people (HLA-DQ2/DQ8)
• Frequency: About 1% of the population; female predominance
• Symptoms: Diarrhea, abdominal pain, failure to thrive, short stature, delayed puberty, iron-deficiency anemia
• Associated disease: Dermatitis herpetiformis; linked with type 1 diabetes, Down syndrome, autoimmune thyroid disease
• Other associations: Other associations include Turner and Williams syndromes and IgA deficiency.

What oral findings occur in Celiac disease?

• Enamel: Symmetric enamel hypoplasia: pits, grooves, banding, opacities
• Mucosa: Recurrent aphthous ulcers, atrophic glossitis, angular cheilitis
• Eruption: Delayed dental eruption

For Celiac disease, how do you distinguish its enamel defects from MIH or fluorosis?

• Celiac: symmetric, chronological defects across all four quadrants
• MIH: asymmetric, demarcated molar/incisor defects
• Fluorosis: diffuse, bilateral changes with a history of excess fluoride exposure during tooth development. Severe fluorosis can include pitting, so pitting does not exclude it. CDC fluorosis definitions.

An 8-year-old has symmetric enamel pits and bands on the permanent incisors and first molars in all four quadrants, plus recurrent aphthae. What do you suspect and what do you do?

Suspect celiac disease, while considering other developmental enamel defects.

• Diagnostic limit: The symmetric pattern suggests a systemic disturbance during tooth formation but does not prove malabsorption.
• Testing: Ask about gastrointestinal symptoms, growth, anemia, and family history; refer for physician-directed testing, usually tissue transglutaminase IgA with total IgA, while the child is still eating gluten.
• Test selection: IgA deficiency changes the test strategy.

Sources

• Supplemental study guide: Pediatric Dental Study Guide: Celiac Disease
• Policy on Nutrition and Dietary Counseling in the Pediatric Dental Setting
• Supplemental genetics: MedlinePlus Genetics: celiac disease
• Supplemental clinical source: NIDDK: Diagnosis of Celiac Disease
• AAPD best practice: AAPD: Management of Dental Patients with Special Health Care Needs (2026)