The Gluten-free Diet
While patients may decide to pursue a gluten-free diet (GFD) for a variety of reasons, it has gained popularity in recent years as a weight loss diet. Despite its trendiness, patients should not follow a GFD to lose weight or to become healthier. Gluten is a protein naturally present in wheat, rye, and barley. According to the Academy of Nutrition and Dietetics “there are no published reports showing that a GFD produces weight loss…”.22 Patients should only follow a GFD if they have a gluten-associated disease confirmed by a physician, due to the potential risk for nutrient deficiencies when eliminating gluten containing nutrient-dense foods.23
There are three health conditions that can be treated with a GFD, and they include: wheat allergy, nonceliac gluten sensitivity, and celiac disease (CD).24 Wheat is one of the top 9 common allergens in the U.S. Patients with a wheat allergy have an abnormal immune response to the protein found in wheat and must therefore, follow a strict wheat-free diet. Since the GFD eliminates all wheat from the diet, it is safe for patients with a wheat allergy. A wheat allergy is an Ig-E mediated reaction that can be mild, and include cutaneous, gastrointestinal or respiratory symptoms, or severe, and result in anaphylaxis. The only current management and treatment for wheat allergy is strict avoidance of wheat and the emergency medication, epinephrine, in the case of anaphylaxis.25 The American Academy of Allergy and Immunology defines anaphylaxis as a “serious allergic response that often involves swelling, hives, lowered blood pressure and in severe cases, shock. If anaphylactic shock isn’t treated immediately, it can be fatal.”26
Patients with nonceliac gluten sensitivity have symptoms after eating gluten-containing grains but do not have medically diagnosed celiac disease or wheat allergy. Reported symptoms include: bloating, gas, abdominal pain, diarrhea, nausea, constipation, headache, joint pain, fatigue, depression, brain fog and neuropathy. Currently, even though there are no validated biomarkers for nonceliac gluten sensitivity, these patients report resolution of symptoms when following a GFD.27
Celiac disease is the world’s most common genetic food intolerance disorder. Gluten is the trigger for an inflammatory T-cell mediated immune response, resulting in villous atrophy of the small intestine, which often leads to GI distress. CD has different pathology and symptomatology in every patient, that includes a wide range of signs and symptoms that mimic other diseases. Therefore, it is extremely difficult to accurately diagnose. Since the first recognizable symptom is often in the oral cavity, oral healthcare providers may be the first healthcare professional to recognize CD. The most common oral symptoms of CD include recurrent aphthous ulcers, reduction of salivary flow, geographic tongue and dental enamel defects. Dental professionals should be versed in being able to recognize the manifestations of CD.28 Dentists should refer patients to the gastroenterologist for diagnosis since early diagnosis of CD is essential to avoid long-term complications. Helping these patients begin to take the necessary steps toward correct early diagnosis and treatment will prevent development of long-term serious complications, that include infertility, miscarriage, osteoporosis, Sjogren’s disease and other autoimmune diseases.29
Once the patient has received the diagnosis, the only treatment currently available for CD is a strict, lifelong GFD. Nutritional counseling from a registered dietitian is recommended in order to make sure that the patient is eating a healthy, nutrient-dense GF diet, thereby preventing nutrient deficiencies.23 The patient must avoid not only all foods, beverages and condiments that contain gluten, they must also avoid any dental product that contains gluten. Dental products that may contain gluten include toothpaste and mouthwash.30 The dental treatment plan must be modified to be certain that all in-office dental products and medications prescribed are GF. Many dental products recommended for home use will state on their label whether or not they are GF. If in doubt, it is recommended to contact the manufacturer directly to confirm GF status of the product.
The bottom line: While the GF diet is not recommended for weight control or weight loss, dental patients who have medically diagnosed CD must follow a strict GFD. A dental patient who has been diagnosed with nonceliac gluten sensitivity may choose to eliminate gluten from the diet to improve symptomatology. A strict wheat-free diet is indicated for a dental patient with an IgE-mediated wheat allergy.