Celiac disease and recurrent aphthous stomatitis.

Celiac disease and recurrent aphthous stomatitis.

Widodo Judarwanto. Children Allergy Online Clinic, Jakarta Indonesia

Celiac disease (CD) is a condition related to the small intestine’s intolerance to gluten. In epidemiologic studies the prevalence is highly variable. The diagnosis can be difficult due to the wide spectrum of signs and symptoms. As the risk for intestinal lymphoma is higher in these patients, early diagnosis has its privileges. The higher prevalence of recurrent aphids stomatitis in celiac disease led us to investigate the celiac disease prevalence in patients with recurrent aphthous stomatitis, which might assist in diagnosis of asymptomatic celiac disease patients. It is important to identify this disease process early because affected individuals have an increased risk for developing lymphoma of the gut.

Recurrent aphthous stomatitis is a common disease of the oral mucosa that is characterized by recurrent, painful ulcers of unknown etiology. The association between celiac disease and recurrent aphthous stomatitis has been evaluated in several studies, but variable results have been reported. Yaşar S, et al. reported study that determine the prevalence of celiac disease in patients with recurrent aphthous stomatitis. Methods: The study group consisted of 82 patients, all of whom had a history of recurrent aphthous stomatitis. The control group included 82 patients who did not have aphthous stomatitis. Patients were screened for IgA anti-endomysial antibodies, IgG anti-endomysial antibodies, IgA anti-gliadin antibodies, and IgG anti-gliadin antibodies. Patients with positive serology underwent endoscopic biopsies of the duodenal mucosa. Patients in both groups were also questioned regarding gastrointestinal symptoms.

There is 1.2 percent of the study group was diagnosed with celiac disease by biopsy. Gastroesophageal reflux disease symptoms, heartburn and regurgitation were determined to be of higher incidence in the study group. None of the 82 patients in the control group were diagnosed as having celiac disease. There is no apparent etiological link between recurrent aphthous stomatitis and celiac disease and that screening recurrent aphthous stomatitis patients for celiac disease has little clinical value. Additionally, regurgitation of gastric acid to the oral cavity may precipitate the formation of aphthous stomatitis.

The study group consisted of patients having a history of recurrent aphthous stomatitis. The control group included patients not having aphthous stomatitis. Antibodies to gliadin IgG and IgA and antibodies to endomysium were determined from the serum samples of all patients. Biopsies were obtained from the distal part of the duodenum.

Biopsies of two patients (4.8%) out of 41 belonging to the study group were diagnosed as celiac disease. In serum samples of both, antibodies to gliadin IgA and antibodies to endomysium were found to be positive. Antibodies to gliadin IgG antibody were positive in only one of these two patients. None of the 49 patients in the control group was diagnosed as celiac disease.

Further evaluation of recurrent aphthous stomatitis patients for celiac disease must be performed. As the endoscopic procedures are invasive and costly, evaluation of recurrent aphthous stomatitis patients for celiac disease must include serologic markers at the beginning. If any positivity is determined in markers, then endoscopic procedures including biopsies of the duodenum must be considered as the second-step intervention.

Sedghizadeh PP, et al. Celiac disease and recurrent aphthous stomatitis: a report and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002 Oct;94(4):474-8.

Sedghizadeh PP, et al.also reported that evaluate whether patients with CD have a significantly higher prevalence of recurrent aphthous stomatitis compared with the general population, as some investigators have speculated. Therefore, these study screened 61 patients with diagnosed CD for the presence of, or a positive history of, aphthous ulcerations. Statistically compared this data with a randomly selected control population, matched for age and gender, but without CD. These study results demonstrated no significant differences between groups for age, gender, or prevalence of recurrent aphthous stomatitis.

IgA and IgG endomysial antibodies

Recurrent aphthous stomatitis is a common disease of the oral mucous membranes. Currently a hypothesis is being discussed that it might be pathogenetically related to coeliac disease. The frequency of coeliac disease anti-endomysial (or anti-transglutaminase) antibodies in patients with recurrent aphthous stomatitis. Blood samples from 42 patients were evaluated and 4.7% were IgA- and IgG-endomysial antibody-positive. None of the 42 persons in the control group had antibodies, which was not statistically different from the patient group. The two antibody-positive patients had episodes of mild gastrointestinal symptoms only, but histopathology of duodenal mucous membranes confirmed coeliac disease. All symptoms related to aphthous stomatitis responded well to a gluten-free diet. Every patient with recurrent aphthous stomatitis should be asked about a history of gastrointestinal complaints and screened for markers of coeliac disease, since recurrent aphthous stomatitis may in some cases respond to a gluten-free diet.

References:

  • Yaşar S, et al. Clinical importance of celiac disease in patients with recurrent aphthous stomatitis. Turk J Gastroenterol. 2012 Feb;23(1):14-8.
  • Celiac disease in patients having recurrent aphthous stomatitis. Turk J Gastroenterol. 2004 Sep;15(3):192-5.
  • Aydemir S, et al. Celiac disease in patients having recurrent aphthous stomatitis. Turk J Gastroenterol. 2004 Sep;15(3):192-5
  • Olszewska M, et al.Frequency and prognostic value of IgA and IgG endomysial antibodies in recurrent aphthous stomatitis. Acta Derm Venereol. 2006;86(4):332-4.
  • Sedghizadeh PP, et al. Celiac disease and recurrent aphthous stomatitis: a report and review of the literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002 Oct;94(4):474-8.

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Curriculum Vitae Dr Widodo judarwanto, Pediatrician

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