A Diagnosis in a Smile


We read with interest the paper by Rashid et al.1 showing that the oral manifestations of celiac disease (CD) are a common finding and may be the only manifestation of this disorder.

We have recently conducted a large prospective study to establish the prevalence of enamel defects and aphthous ulcers in a large group of children with CD (212 patients) compared to healthy controls (350 children). We have found an overall prevalence of dental enamel defects as high as 76% in celiac patients as compared to 36% in controls with an odds ratio of more than 5. Most of the lesions are grade I and are therefore difficult to detect with an inexperienced eye. Similarly, recurrent aphthous stomatitis was more frequent in celiac patients as compared to healthy children (17% vs. 3%; odds ratio: 7/1). Interestingly, for 80% of celiac patients with recurrent aphthous stomatitis, this condition was resolved after 1 year of a gluten-free diet.

Our experience reinforces the need for a close collaboration between gastroenterologists and a highly experienced dental team since most of the lesions that were identified may pass undetected. This might explain the high variability in prevalence of enamel defects reported in various studies, ranging from 10% to more than 80%.2

We believe that the care of patients with celiac disease should be managed with a multidisciplinary approach; in addition to a gastroenterologist and a dietitian, an odontologist might be helpful. Finally, we believe that greater efforts should be made to inform general practitioners about oral problems as potential clinical markers of celiac disease, as this knowledge may help to raise the alarm and let the “celiac iceberg” emerge: “Think of CD and you will find it.”3


Dr. Savino Cefola
Dr. Antonia Sinesi
Dr. Ruggiero Francavilla
Bari, Italy


  1. Rashid M, Zarkadas M, Anca A, Limeback H. Oral manifestations of celiac disease: a clinical guide for dentists. J Can Dent Assoc. 2011;77:b39.
  2. Procaccini M, Campisi G, Bufo P, Compilato D, Massaccesi C, Catassi C, et al. Lack of association between celiac disease and dental enamel hypoplasia in a case-control study from an Italian central region. Head Face Med. 2007;3:25.
  3. Fasano A, Catassi C. Current approaches to diagnosis and treatment of celiac disease: an evolving spectrum. Gastroenterology. 2001;120(3):636-51.