It was a typical Tuesday at the office when one of my front office teammates quietly approached me in my operatory. I could sense the irritation in her voice as she whispered, “Your next patient, Diane, just checked in. She’s asking if you’ll be using any products containing gluten during her visit today and wants to make sure you’re aware that she was recently diagnosed with celiac disease. I just wanted to give you fair warning that she’s going to grill you about gluten once you bring her back.”
I thanked her for the heads-up and continued setting up my room. As I pulled the headrest cover over my chair, I paused for a moment to contemplate some growing questions I had in response to Diane’s concerns: How much do I really know about celiac disease? Gluten is only in food products, right? What might happen to Diane if she is inadvertently exposed to a little gluten during her visit today?
The more I pondered, the more I panicked. I didn’t like knowing that I could ultimately be risking my patient’s safety with my ill-informed assumptions, so I rushed to my computer to start researching.
What I found out about celiac disease
Celiac disease is an autoimmune condition caused by the small intestine’s sensitivity to gluten, a type of protein found primarily in foods containing wheat, rye, and barley. It is estimated that about one in 150 Americans suffers from this disease, including many individuals who are currently undiagnosed.1
- Gut health: A key link between oral and systemic wellness
- Fructose and lectins: Health disrupters or not?
Due to an exaggerated immune response, the villi (fingerlike projections) that line the small intestine begin to atrophy with continued exposure to gluten, which ultimately results in body-wide complications. Primary symptoms include diarrhea and/or constipation, abdominal pain, bloating, fatigue, and weight loss. Aside from gastrointestinal (GI) symptoms, a person can experience malabsorption of vital nutrients, headaches, iron-deficiency anemia, skin issues, osteoporosis or osteomalacia, joint pain, and neurological dysfunction. Inability to manage symptoms can eventually lead to infertility, miscarriage, and intestinal cancers. To properly diagnose celiac disease, a physician will order blood work to analyze serum levels and eventually confirm findings via endoscopy and possible intestinal biopsy.2
How celiac disease affects oral health
Oral manifestations of celiac disease could include varying degrees of enamel defects and delayed tooth development if the patient suffered early onset during childhood. Additionally, these patients tend to be more at risk for caries due to a lack of calcium and phosphorous in the enamel structure. Regardless of the patient’s age when he or she began experiencing celiac symptoms, bouts with aphthous ulcers can be common if their condition is not well managed.3 It is important to be aware of the underlying cause of these findings so that the proper support can be provided to the patient in the form of dietary counseling, caries prevention, and ulcer relief.
Challenges with celiac disease
Unlike most other health conditions where medication is available to treat the disease, the only way to successfully treat celiac disease is to eliminate gluten from the diet. As you can imagine, this can be very stressful and challenging for the patient. With just a small amount of gluten ingestion, the patient’s celiac symptoms can return and will require additional time and effort to manage the flare-up.
Not only does the patient have to be watchful of possible gluten added to food and beverages, but there are also many nonfood items that have been known to contain this wheat protein due to its elastic nature and ability to thicken and bind to substances. Gluten can sometimes be found in cosmetic products, medications, supplements, skin and hair products, Play-Doh, and, unfortunately, some dental care products.4
According to the Food and Drug Administration (FDA), there are standards that must be met for a product to be advertised as “gluten-free,” but the manufacturer’s decision to label whether or not a product is gluten-free is completely voluntary.5 This can leave patients with celiac disease feeling very uneasy about trying new foods or products they are unfamiliar with, especially when they are in an environment where they can’t personally evaluate the ingredients or packaging to determine if certain products are safe for them. When considering this, it is understandable why patients may feel especially apprehensive coming to the dental office where products with unknown ingredients are used in and around the oral cavity. This is where dental professionals can work to better support and protect patients who cannot safely consume gluten.
Gluten and dental products
Developing an awareness of dental product ingredients is the first step in advocating for patients with celiac disease. Since the FDA does not require manufacturers to specifically label whether a product contains gluten, we must assume the possible presence of gluten in all unlabeled products. Many dental manufacturers have recognized this concern and are working to label their gluten-free products as such. Check the packaging of your prophy pastes, therapeutic agents, fluoride products, whitening systems, and patient samples for this gluten-free label. If your product does not specifically indicate gluten-free, you may want to consider purchasing a small amount of a certified gluten-free option for your celiac patients.
While researching this topic, I was surprised at how difficult it is to find oral care products with a gluten-free description directly from the manufacturer, even for products that many of us would classify as “natural” or “clean.” An internet search might reveal a personal wellness blog or health website article claiming a product to be gluten-free when there is no such language on the product’s official website or packaging. As with any other health-related information, be cautious when considering these online sources. This is an area where many oral care product manufacturers have an opportunity to be more transparent about their product ingredients to support individuals with celiac disease and the oral health-care providers who care for them. Click here for a helpful reference of advertised gluten-free products.
Many dental professionals are not aware that gluten can also be present in some types of oral prostheses and appliances, specifically those made with a popular acrylic resin called methyl methacrylate (MMA). Orthodontic retainers, fixed and removable dentures, temporary crowns, and denture repair material are types of products typically made with MMA.6 It was discovered in recent years that the nondietary gluten found in MMA can trigger symptoms in patients with celiac disease and should be avoided.7
How we can help our patients with gluten sensitivity
Another way we can better serve our patients with celiac disease is to ensure that we are providing a personal encounter that is safe and trusting. Making sure to document the condition in the patient’s medical history may seem like a given, but this identifier also serves as an important reminder to prepare the operatory with necessary gluten-free products without the patient having to make the request.
Changing out of our personal protective equipment (PPE) before lunch breaks and properly washing our hands after eating are small, yet significant, precautionary measures we can take to minimize potential gluten exposure to our patients. Verbally reassuring patients with an explanation of the special steps being taken will not only put them at ease while in our care but will also build a patient-provider relationship based on respect and empathy.
As dental professionals, our patients’ health concerns may cause us to feel panicked or overwhelmed when our schedules are tight and our current knowledge is limited. But it is important to remember that the individuals we care for have unique physical and emotional needs, and we are here to meet them. It’s our responsibility—and privilege—to treat the human in our hygiene chair. Best wishes!
Editor's note: This article originally appeared in the February 2022 edition of RDH.
- Liu E. Celiac disease. AccessScience. McGraw-Hill Education. Updated April 2020. Accessed October 26, 2021. https://doi.org/10.1036/1097-8542.115950
- Celiac disease. Mayo Clinic. August 10, 2021. Accessed October 15, 2021. https://www.mayoclinic.org/diseases-conditions/celiac-disease/symptoms-causes/syc-20352220
- Malahias T. Oral health. Celiac Disease Foundation. Accessed October 23, 2021. https://celiac.org/about-celiac-disease/related-conditions/oral-health/
- Treatment for celiac disease: How do doctors treat celiac disease? National Institute of Diabetes and Digestive and Kidney Diseases. Updated October 2020. Accessed October 11, 2021. https://www.niddk.nih.gov/health-information/digestive-diseases/celiac-disease/treatment
- Gluten-free labeling of foods. U.S. Food & Drug Administration. Updated August 12, 2020. Accessed October 23, 2021. https://www.fda.gov/food/food-labeling-nutrition/gluten-free-labeling-foods
- Zafar MS. Prosthodontic applications of polymethyl methacrylate (PMMA): an update. Polymers (Basel). 2020;12(10):2299. doi:10.3390/polym12102299
- Memon Z, Baker SS, Khan A, Hashmi H, Gelfond D. An orthodontic retainer preventing remission in celiac disease. Clin Pediatr (Phila). 2013;52(11):1034-1037. doi:10.1177/0009922813506254