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 her safety with my ill-informed assumptions, so I rushed to my computer to start researching.
What is 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’s estimated that about one in 150 Americans suffers from this disease, including many individuals who are currently undiagnosed.1 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 bodywide complications. Primary symptoms include diarrhea and/or constipation, abdominal pain, bloating, fatigue, and weight loss. Aside from 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 with endoscopy and possible intestinal biopsy.2
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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 they began experiencing celiac symptoms, bouts with aphthous ulcers can be common if their condition is not well managed.3 Awareness of the underlying cause of these findings can help provide proper support to the patient in the form of dietary counseling, caries prevention, and ulcer relief.
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—which can be very stressful and challenging for patients. With just a small amount of gluten ingestion, celiac symptoms can return and the patient will need additional time and effort to manage the flareup. Patients have to be watchful of possible gluten not only added to food and beverages, but also to many non-food items that contain this wheat protein due to its elastic nature and ability to thicken and bind 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 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 a product is gluten-free is completely voluntary.5 This can leave a patient with celiac disease feeling very uneasy about trying new foods or products, especially when they’re in an environment where they can’t personally evaluate the ingredients or packaging to determine if certain products are safe for them. So it’s understandable that patients may feel especially apprehensive coming to the dental office where products with unknown ingredients are used in and around their mouth. This is where dental professionals can work to better support and protect patients who cannot safely consume gluten.
How dental professionals can help
In advocating for patients with celiac disease, developing an awareness of gluten in dental products is the first step. Since manufacturers are not required by the FDA 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 toward labelling 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 that it’s gluten-free, you may consider purchasing a small amount of a certified gluten-free option for your celiac patients. 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 products typically made with MMA.6 It was discovered in recent years that the nondietary gluten found in this material can trigger symptoms in patients with celiac disease and should be avoided.7
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. Documenting the condition in the patient’s medical history may seem like a given in the general sense, 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. Making sure to change out of your PPE before lunch breaks and properly washing your hands after eating are small yet significant precautionary measures you can take to minimize potential gluten exposure to your patients. Verbally reassuring them with an explanation of the special steps you’re taking will not only put them at ease while in your care; it will also help 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 schedule is tight and our current knowledge is limited. But we need 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.
References
1. Liu E. Celiac disease. AccessScience. Accessed October 26, 2021. https://doi-org.ezproxy.aclin.org/10.1036/1097-8542.115950
2. Celiac disease. Mayo Clinic. August 10, 2021. Accessed October 15, 2021. https://www.mayoclinic.org/diseases-conditions/celiac-disease/symptoms-causes/syc-20352220
3. Malahias T. Oral Health. Celiac Disease Foundation. Accessed October 23, 2021. https://celiac.org/about-celiac-disease/related-conditions/oral-health/
4. Treatment for celiac disease: How do doctors treat celiac disease? National Institute of Diabetes and Digestive and Kidney Diseases. October 2020. Accessed October 11, 2021. https://www.niddk.nih.gov/health-information/digestive-diseases/celiac-disease/treatment
5. Gluten-free labeling of foods. US Food & Drug Administration. August 12, 2020. Accessed October 23, 2021. https://www.fda.gov/food/food-labeling-nutrition/gluten-free-labeling-foods
6. Zafar MS. Prosthodontic Applications of Polymethyl Methacrylate (PMMA): An Update. Polymers (Basel). 2020;12(10):2299. October 8, 2020. doi:10.3390/polym12102299
7. 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
