nice teeth smile
© Ingram Publishing/Thinkstock

Celiac disease doesn't just affect the gut. It can have widespread impact throughout your body, from your skin and joints to your mood and brain. Research shows your pearly whites can also be affected, especially in children.

The year before I was diagnosed with celiac disease, at age 25, I got my first cavity. Six months later, I was back in the dentist chair getting two more fillings. As luck would have it, one of these cavities went rogue on me when I was on vacation and I developed hot, pulsing pain on the side of my face. Two days later, I underwent a root canal.

It's been ten years since my celiac diagnosis and I haven't had another cavity. I've often wondered: Could undiagnosed celiac disease have affected my teeth?

Dental Issues Aren't Widely Known

It turns out there's no published research directly linking cavities to celiac disease. But celiac disease can affect the mouth and teeth, especially the tooth enamel.

Enamel is the translucent, tough outer shell of the tooth. It protects teeth from damage and allows you to chew and eat hot and cold foods without discomfort. Multiple studies in multiple countries show defects to this tough shell are more common in people with celiac disease, says celiac expert Peter H.R. Green, MD, director of the Celiac Disease Center at Columbia University Medical Center.

These defects, which range from innocuous white or yellow spots to deep ridges and misshapen teeth, are especially common in celiac children. They can affect celiac adults, too, but they're harder to spot.

"Adults are more likely to have had extensive dental work with bonding, caps and crowns. You don't always know what all that was for," says Green. "Could it have been damage due to celiac disease?"

In fact, there's a wide range of reasons for enamel defects. Perhaps the biggest culprit is too much fluoride. (This is usually a cumulative result of drinking highly fluoridated water and swallowing a lot of fluoride toothpaste and fluoride rinse, not exposure from the dentist.) Antibiotic use, especially tetracycline, is also widely blamed for enamel defects. But certain clues point to celiac disease, says Ted Malahias, DDS, who practices general dentistry in Groton, Connecticut.

"With celiac disease, the defects are bilateral and symmetrical. They're also chronological, which means they're found on teeth that develop at the same age although the teeth may be located in different parts of the mouth," Malahias says. "You're not just going to have one tooth with marring. You'll see marks in all four quadrants of the mouth. For example, you'll have these marks on all four incisors. It almost looks like someone colored them in."

Malahias became interested in celiac disease and its impact on dental health after his wife and daughter, then 7, were both diagnosed with the autoimmune disorder.

"I had no idea what my daughter's gastroenterologist was looking for when he examined her teeth," he says. "I later learned her doctor had done his training in Europe where they've been studying the dental associations of celiac disease since the 1990s."

Malahias contacted Peter Green and the two worked on the first U.S.-based study on celiac disease and dental health. In 2009, they published their results, which showed celiac individuals, especially children, have nearly triple the rate of enamel defects than the non-celiac population.

Can the Gluten-Free Diet Help?

It's still not clear how celiac disease affects dental enamel. But because the enamel of permanent teeth develops by about age seven, experts think only early-onset celiac disease is associated with enamel defects. So a person who develops celiac at 20 or 30 shouldn't have these defects.

Celiac experts draw a parallel between the occurrence of enamel defects and a phenomenon described as altered craniofacial growth (translation: large foreheads). In Southern Italy, researchers observed that the foreheads of celiac children there were larger than normal (i.e., longer than the lower half of the face). Researchers think that the central part of the facial bones may not develop properly in youngsters with untreated celiac disease. This altered craniofacial growth hasn't been documented elsewhere in the world.

Unfortunately, the gluten-free diet won't fix existing enamel defects. Unlike bone, enamel has no living cells to repair itself. However, the appearance of the teeth can be improved by bleaching white or yellow spots. More extensive defects can be treated with cosmetic bonding or veneers.

"Ideally, you catch celiac disease early in a young child so you have a chance to prevent or at least lessen the potential insult to enamel by initiating a gluten-free diet," says Malahias, who notes that the gluten-free diet can also help prevent aphthous ulcers (canker sores), which have been linked to celiac disease.

In their study, Malahias and Green showed that canker sores were twice as common in celiac children and adults, compared to control subjects.

"We saw a definite connection between the gluten-free diet and decreased occurrence of aphthous ulcers. Patients who used to get them every month were only getting just two to three a year once they eliminated gluten."

Malahias has lectured around the country to raise awareness about the link between celiac disease and oral health. (There's not yet any indication that non-celiac gluten sensitivity affects dental health.)

Many dentists aren't aware of the oral presentations of celiac disease, says Malahias. Although they can't diagnose celiac disease, dentists have an opportunity to help identify potential cases.

"Symmetrical and chronological defects should prompt further investigation. Dentists should ask about migraines, stomach issues, diarrhea, joint pain and other autoimmune diseases," he says. "If I saw a child with characteristic enamel markings, reflux and anemia, I'd urge the parents to follow up with the child's doctor."

But don't go gluten-free before testing for celiac disease, stresses Malahias. You need regular gluten in the diet for testing to be accurate.

Comment: That does not sound like good advice. Considering the lab testing for celiac disease is not 100%, and it doesn't pick up non-celiac gluten sensitivity, the best test for gluten sensitivity is to eliminate gluten and see if there are improvements.

Open Wide!

Exposure to gluten at the dentist is very limited, says Peter H.R. Green, MD, director of the Celiac Disease Center at Columbia University Medical Center. Major manufacturers of dental adhesives, impression materials, cements and restorative materials do not include gluten in their formulations, says Ted Malahias, DDS. In addition, gluten-free fluoride and gluten-free prophy paste (the gritty paste used to polish teeth) are now widely available. Many dental supply catalogues also list these products as nut-free, dye-free, aspartame-free and latex-free.

Most of the popular consumer toothpaste and mouthwash brands-Crest, Colgate, Aquafresh and Sensodyne-state on their websites that they do not contain gluten. For toothpaste with a gluten-free label, buy Tom's of Maine, suggests Suzanne Simpson, RD, a registered dietitian at the Celiac Disease Center at Columbia University Medical Center.

Concerned about floss? Sometimes dental floss is coated with mint flavoring. Malahias says he's never found floss to be a problem for celiac patients. If you're concerned, check directly with the manufacturer.