nutrients Article Tooth Wear Is Frequent in Adult Patients with Celiac Disease Massimo Amato †, Fabiana Zingone †, Mario Caggiano ID , Paola Iovino, Cristina Bucci and Carolina Ciacci * Department of Medicine, Surgery and Dentistry, Medical School of Salerno, 84131 Salerno, Italy; [email protected] (M.A.); [email protected] (F.Z.); [email protected] (M.C.); [email protected] (P.I.); [email protected] (C.B.) * Correspondence: [email protected]; Tel.: +39-335-7816758 † These authors contributed equally to this paper. Received: 26 September 2017; Accepted: 30 November 2017; Published: 4 December 2017 Abstract: (1) Background: Celiac disease (CD) patients can be affected by mouth and tooth disorders, which are influenced by their gluten-free diet. The aim of our research was to evaluate the pathological conditions of the stomatognathic system observed in celiac patients on a gluten-free diet. (2) Methods: we consecutively recruited celiac patients on a gluten-free diet at our celiac center, as well as healthy volunteers. Two dentists examined all patients/controls and checked them for any mouth disorder. (3) Results: Forty-nine patients affected by celiac disease (age at test 31.8 ± 11.58, time on GFD 8.73 ± 7.7) and 51 healthy volunteers (age at test 30.5 ± 8.7) were included. Recurrent aphthous stomatitis was reported in 26 patients (53.0%) and in 13 (25.5%) controls (p = 0.005). Dental enamel disorders were reported in 7 patients (14.3%) and in 0 controls (p = 0.002), with none having geographic tongue. We found non-specific tooth wear, characterized by loss of the mineralized tissue of the teeth, in 9 patients (18.3%) and in 3 (5.9%) controls (p = 0.05). (4) Conclusion: Recurrent aphthous stomatitis and enamel hypoplasia are “risk indicators” that may suggest that an individual has CD. We detected a high prevalence of non-specific tooth wear that can be caused by several factors such as malocclusion, sleep bruxism, parafunctional activity, and age. Keywords: enamel hypoplasia; tooth wear; aphthosis; celiac disease 1. Introduction Celiac disease (CD) is an immune-mediated systemic disorder caused by gluten, a protein found in wheat and some related cereals. In genetically susceptible individuals, gluten induces CD-specific antibodies (anti-transglutaminase and anti-endomysial antibodies) and enteropathy [1,2]. The prevalence of CD is about 1% in Europe and the USA, and evidence shows that it is increasing worldwide [3–5]. The clinical presentation of CD ranges from a severe malabsorption syndrome to a number of extraintestinal symptoms [2]. Additionally, screening programs among first-degree relatives of patients with CD, or patients with other autoimmune disorders, aid CD diagnosis in subjects with subclinical presentation or no symptoms [6]. It is now widely recognized that mouth and tooth disorders can affect CD [7,8]. Enamel hypoplasia and recurrent aphthous stomatitis (RAS) have been the subject of many studies, with a particular focus on children. It is well-known that gluten exclusion does not influence the enamel hypoplasia, since the damage has already been established and it is irreversible [7,8], whereas RAS improves on a gluten-free diet (GFD) [9]. Atrophic glossitis (also known as geographical tongue) is instead reported in CD before diagnosis [10]. The aim of our study was to evaluate the pathological conditions of the stomatognathic system (teeth and oral mucosa) observed in CD patients on a GFD. Nutrients 2017, 9, 1321; doi:10.3390/nu9121321 www.mdpi.com/journal/nutrients Nutrients 2017, 9, 1321 2 of 9 Nutrients 2017, 9, 1321 2 of 9 2. Materials and Methods Over aa period period ranging ranging from from September September 2015 to2015 April to 2016,April we 2016 consecutively, we consecutively recruited arecruited population a composedpopulation ofcomposed CD patients of CD on patients a GFD,enrolled on a GFD, at theenrolled Gastroenterology at the Gastroenterology Department Department of the University of the ofUniversity Salerno, of as Salerno, well as as healthy well as volunteers healthy volunteers recruited amongrecruited the among hospital the staffhospital and staff the CDand patients’ the CD friends.patients’ Twofriends. dentists Two dentists (MA and (MA MC) and examined MC) examined all the all patients the patients together. together They. They did notdid attendnot attend the gastroenterologicalthe gastroenterological visit, visit and, and therefore therefore they they did did not not know know to to which which group group thethe subjectssubjects belonged (patient(patient or control).control). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/orand/or national national research research committee committee and with the 1964 Helsinki declaration and its later amendmentsamendments oror comparablecomparable ethicalethical standards.standards. This study protocol was approved byby RegioneRegione Campania,Campania, San San Giovanni Giovanni di di Dio Dio e e Ruggi Ruggi D’Aragona, D’Aragona, Salerno Salerno Ethic Ethic Committee Committee in datein date 29 29 October October 2012 2012 with with approval approval code code 836. 836. Written informed consentconsent waswas obtainedobtained fromfrom allall individualindividual participantsparticipants includedincluded inin thethe study.study. The inclusion criteria for the celiac group were: age older than 18 years; positive CD-specificCD-specific serology (anti-transglutaminase(anti-transglutaminase IgA IgA and and antiendomysial antiendomysial IgA IgA in absence in absence of IgA of deficiency) IgA deficiency) and positive and intestinalpositive intestinal biopsy, orbiopsy, a B-C or grade a B-C histology grade histology according according to Corazza-Villanacci to Corazza-Villanacci classification classification [11] before [11] startingbefore starting the GFD. the AllGFD. CD All patients CD patients had to had have to beenhave onbeen a GFD on a forGFD at for least at oneleast year one andyear have and beenhave anti-transglutaminasebeen anti-transglutaminase IgA negativeIgA negative at the at time the time of the of examination. the examination. We excludedWe excluded patients patients who who had receivedhad received the CD the diagnosisCD diagnosis before before the age the ofage 3 (whenof 3 (when deciduous deciduous teeth teeth should should be completed). be completed). Inclusion criteria criteria for for the the control control group group were: were: age age older older than than 18 years; 18 years; negativity negativity to anti to- anti-transglutaminasetransglutaminase antibodies; antibodies; no gastroenterological no gastroenterological disease; disease; no infectious, no infectious, immune immune-mediated,-mediated, or orauto auto-immune-immune disorder. disorder. Demographics and clinical information were collected during the gastroenterological visit,visit, and data were recorded in a dedicateddedicated database. At the moment of the dental visit,visit, patients were asked about recurrent aphthous stomatitis (RAS) characterized by recurrent bouts of solitary or multiple shallow painfulpainful ulcers,ulcers, at at intervals intervals of of a fewa few months months to ato few a few days days in patients in patients who who were were otherwise otherwise well (Figurewell (1)1 [12])[12. ].Aphthosis Aphthosis at at the the time time of of the the exam exam was was also also detected. detected. Figure 1. A case of aphthosis on the buccal mucosa.mucosa. The color, type, and site of dental enamel defects were recorded and classified classified according to Aine classificationclassification [[8,13]8,13].. According to Aine, enamel defects appear symmetrically and chronologically in the same anatomical groups of teeth in all four quadrants of dentition, while single and asymmetrical changes were regarded as highly unspecific unspecific to CD. Enamel hypoplasia, in particular, is characterized by a reduced deposition of the enamel matrix by the ameloblasts. This alteration is clinically featured by depressions or grooves on the surface ofof thethe toothtooth (Figure(Figure2 2).). Nutrients 2017, 9, 1321 3 of 9 Nutrients 2017, 9, 1321 3 of 9 Figure 2: 2. A case of enamel hypoplasia in a celiac disease (CD)(CD) patient.patient. Depending on the severity, it can vary from a mere change of color towards chalky white or gray Depending on the severity, it can vary from a mere change of color towards chalky white or gray and brownish, to areas of leakage of substances, up to severe cases of complete absence of enamel. and brownish, to areas of leakage of substances, up to severe cases of complete absence of enamel. Finally, the presence of atrophic glossitis (geographic tongue) was detected, which is characterized Finally, the presence of atrophic glossitis (geographic tongue) was detected, which is characterized by by glossodynia, atrophy of the filiform papillae, and erythematous areas on the back of the tongue. glossodynia, atrophy of the filiform papillae, and erythematous areas on the back of the tongue. Statistical Analysis Statistical Analysis Categorical and continuous variables were expressed as frequency and mean ± standard Categorical and continuous variables were expressed as frequency and mean ± standard deviation deviation (SD), respectively. Differences in frequencies between the groups were calculated using the (SD), respectively. Differences in frequencies between the groups were calculated using the c2 test, χ2 test, while differences between continuous