Serological study of celiac disease in children with dental caries

1. Introduction

Celiac disease is an autoimmune disease caused by the malabsorption of nutrients in the small intestine that results from eating gluten-containing substances including wheat, barley, oats, and rye. The prevalence of celiac disease in children has been reported to be 3–13 per thousand based on studies conducted in Europe and the United States [1]. According to research conducted in Iran, the prevalence of this disease is estimated at 1 in 104 of the general population, which indicates that the prevalence of celiac disease in Iran is high [2]. This disease affects all age groups and its manifestation varies from asymptomatic cases to symptoms of significant food absorption with diarrhea, steatorrhea and weight loss [3].

The most common cause of persistent symptoms and complications in celiac disease is continued gluten consumption, and more than 90% of patients respond to a gluten-free diet. The most important complication of celiac disease is gastrointestinal malignancies, especially intestinal lymphoma, which can be prevented by early detection of celiac disease and the use of a gluten-free diet [4]. Antibody studies used to diagnose celiac disease include anti-gliadin, anti-endomysial antibodies, tissue anti-transglutaminase (high sensitivity and specificity) and its screening test is Anti TTG (IgA) [5]. After using serological tests, the diagnosis is based on typical clinical signs of the disease [6]. Among the complications of not treating celiac disease are developmental disorders, osteoporosis and intestinal lymphoma [7]. According to recent studies, it seems that celiac disease can cause oral manifestations such as delayed tooth growth, decreased saliva, recurrence of oral pests and enamel defects in both deciduous and permanent teeth [8]. Tooth decay is the most common infectious disease of the mouth and teeth caused by acidogenic bacteria and causes dissolution and destruction of tooth structures (enamel and dentin) and ultimately inflammation of the dental pulp. Given a higher prevalence of tooth decay in patients with celiac disease, and the accessibility to serological tests that lead to early diagnosis of the disease, we examined the incidence of celiac disease in children aged 3 to 12 years old.

2. Methods

The present study was a cross-sectional study. The statistical population of the study were children with dental caries referred to dental clinics in Ilam province during 2019–2020.The inclusion criteria were as followed; 3 to 12 years old children with confirmed diagnosis of tooth decay and without gastrointestinal diseases and the exclusion criteria were; Children with infectious causes of diarrhea such as Shigella, Giardia, dysentery and cases of autoimmune disorders and gastrointestinal disorders (GERD) and dissatisfaction with participation in the study. Among the patients referred to the Dental Clinic of Ilam University of Medical Sciences, the dentist referred 3 to 12-year-old children with enamel caries and involved in the study if they had the conditions to enter the study and their parents had full consent about their participation. After selecting the study group, a blood samples were taken and sent to a laboratory. The levels of total serum IgA and anti-TTG (Anti TTG IgA) antibody were analyzed. A demographic information checklist (including age, sex, history of breastfeeding, number of decayed teeth, parents’ education, and patient’s residence) was filled for each patient. AESKUL kit (Germany) was used to analysis the anti-TTG (IgA) antibody level. According to the standard set in the kit, the titer less than 15 U/ml was negative and levels more than this were considered positive. Data analysis was performed using SPSS.ver19 software. Descriptive statistics and Chi-square test were used. Significance level of tests was considered to be less than 0.05.

Ethical code: ir.medilam.rec.1396.22.

3. Results

In this study 120 children with tooth decay were included. The distribution of age, sex, number of decayed teeth, breastfeeding, maternal education, and pediatric serology is presented in Table 1. Table 1 shows the relationship between serology and tooth decay in terms of sex, age, number of decayed teeth, maternal education, and place of residence and nutrition using chi-square test at a significant level of 0.05. Serological status in children was significantly related to sex, maternal education and place of residence ( P -value ⩽ 0.05).

Celiac disease is a chronic autoimmune disorder associated with intolerance to gluten polypeptides and is also defined as gluten-sensitive enteropathy [48]. Patients with celiac disease can show symptoms in the oral cavity as part of the gastrointestinal tract. The most common oral symptoms that have been studied in various studies are recurrent aphthous stomatitis, enamel developmental disorder and atrophic glossitis [49]. Due to the fact that celiac disease has a high prevalence in society and, on the other hand, this disease can lead to disorders in the Children’s growth and development. In this study we evaluated the relationship between celiac disease and tooth decay based on various variables.120 children as 56 girls (46.7%) and 64 boys (53.3%) with dental caries were with the positive celiac serology rate of 14 (11.6%) involved in the study. Zoumpoulakis et al. reported a 4.64% prevalence of enamel anomalies in patients with celiac disease that showed the presence of enamel abnormalities could be used as a warning sign for asymptomatic cases of celiac disease [41]. In our study, the prevalence of celiac disease in girls was higher with dental caries and had a significant relationship ( P = 0.01), which was not in line with the results of Páez et al. [54]. Other studies have found that the incidence of dental anomalies in celiac disease is not related to sex, age, fluoride intake, or other diseases. In this study, there was no significant relationship between age and celiac disease ( $P>$ 0.05), which is in agreement with the results of Páez et al. [54]. Based on the results of this study, there was a significant relationship between maternal education and place of residence and celiac disease ( 0.05). Also, no a significant relationship was obtained between positive celiac serology in children with dental caries, the number of decayed teeth, and breastfeeding ( $P>$ 0.05). Bicak et al. found that oral cavity disorders are a common finding in children with celiac disease and could help in early celiac disease diagnosis. Fasano et al. showed that because celiac disease is mostly atypical and even clinically silent, in many cases it can often go undiagnosed but lead to many complications throughout life. Despite the differences reported in the results of different studies, a lot of studies show that oral manifestations, including tooth decay, are highly prevalent in celiac disease and can play an important role in the diagnosis of celiac disease in children. In previous studies, the rate of dental anomalies in celiac patients was higher than healthy children and it was shown that the rate of anomalies in celiac patients was not related to sex, age, fluoride intake and other diseases [41, 42, 43]. A prevalence of 64.4% of enamel anomalies in patients with celiac disease was reported which indicate that the presence of enamel abnormalities could be used as a warning sign for asymptomatic cases of celiac disease [44]. It was shown that oral cavity disorders are common in children with celiac disease and can help in the early diagnosis of celiac disease [45]. Bucci et al. showed that the prevalence of enamel anomalies was 20% and 5.6% in patients with celiac disease and control group, respectively. In addition, in this study, a higher prevalence of oral plague was observed in patients with celiac disease compared to control group [50]. A study conducted in Sweden showed that celiac disease and its treatment did not have a significant effect on the mineralization of permanent teeth and the prevalence of enamel anomalies in patients with celiac disease was not different from healthy individuals [51]. Despite the differences reported in the literature, a lot of studies show that oral manifestations, including tooth decay, are highly prevalent in celiac disease and can play an important role in the diagnosis of celiac disease in children. Fasano et al. showed that because celiac disease is mostly atypical and even clinically silent, in many cases it can go undiagnosed but lead to many complications throughout life [52]. Complications of celiac disease can be ranged from mild and treatable to severe. For example, in a study, focal white-matter lesions in brain were identified as an extraintestinal manifestation of celiac disease [53]. With an accurate and timely diagnosis of celiac disease, various complications of this disease can be prevented.

5. Conclusion

The present study showed that dental caries might be a red flag indicating possible celiac disease and the early diagnosis due to the presence of the dental problems will lead to the prevention of complications as well as introducing the diet can earlier. On the other hand, pediatricians and dentists should be aware of the oral symptoms of celiac disease. Further studies are needed to plan screening for children with celiac disease.