Download CDHO Advisory Celiac Disease

CDHO Advisory | Celiac Disease
COLLEGE OF DENTAL HYGIENISTS OF ONTARIO ADVISORY
ADVISORY TITLE
Use of the dental hygiene interventions of scaling teeth and root planing including curetting
surrounding tissue, orthodontic and restorative practices, and other invasive interventions
for persons 1 with celiac disease.
ADVISORY STATUS
Cite as
College of Dental Hygienists of Ontario, CDHO Advisory Celiac Disease, 2011-03-01
INTERVENTIONS AND PRACTICES CONSIDERED
Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and
restorative practices, and other invasive interventions (“the Procedures”).
SCOPE
DISEASE/CONDITION(S)/PROCEDURE(S)
Celiac disease
INTENDED USERS
Advanced practice nurses
Dental assistants
Dental hygienists
Dentists
Denturists
Dieticians
Health professional students
Nurses
Patients/clients
Pharmacists
Physicians
Public health departments
Regulatory bodies
ADVISORY OBJECTIVE(S)
To guide dental hygienists at the point of care relative to the use of the Procedures for
persons who have celiac disease, chiefly as follows.
1. Understanding the medical condition.
2. Sourcing medications information.
3. Taking the medical and medications history.
4. Identifying and contacting the most appropriate healthcare provider(s) for medical
advice.
1
Persons includes young persons and children
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5. Understanding and taking appropriate precautions prior to and during the Procedures
proposed.
6. Deciding when and when not to proceed with the Procedures proposed.
7. Dealing with adverse events arising during the Procedures.
8. Keeping records.
9. Advising the patient/client.
TARGET POPULATION
Child (2 to 12 years)
Adolescent (13 to 18 years)
Adult (19 to 44 years)
Middle Age (45 to 64 years)
Aged (65 to 79 years)
Aged 80 and over
Male
Female
Parents, guardians, and family caregivers of children, young persons and adults with celiac
disease.
MAJOR OUTCOMES CONSIDERED
For persons who have celiac disease: to maximize health benefits and minimize adverse
effects by promoting the performance of the Procedures at the right time with the
appropriate precautions, and by discouraging the performance of the Procedures at the
wrong time or in the absence of appropriate precautions.
RECOMMENDATIONS
UNDERSTANDING THE MEDICAL CONDITION
Terminology used in this Advisory
Resources consulted
 Canadian Celiac Association
 Canadian Society of Intestinal Research
 National Digestive Diseases Information Clearinghouse
1. Aphthous stomatitis, canker sores, a type of stomatitis that presents with shallow,
painful ulcers.
2. Atrophic glossitis, a condition in which papillae are lost from the dorsum of the tongue,
resulting in a sore and highly sensitive surface that makes eating difficult.
3. Celiac disease, celiac sprue, sprue, gluten intolerance, gluten-sensitive enteropathy,
non-tropical sprue, which
a. damages the absorptive surface of the small intestine
b. leads to malabsorption.
4. Cholesterol, is
a. a waxy fat called a lipid produced naturally in the body
b. essential for the body to make
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5.
6.
7.
8.
9.
10.
i. cell membranes
ii. vitamin D
iii. hormones
c. of two types
i. low-density lipoprotein (LDL), the ‘bad’ cholesterol
ii. high-density lipoprotein (HDL), the ‘good’ cholesterol because it carries
LDL away from the arterial walls where the atherosclerosis accumulates.
Dermatitis herpetiformis, an intensely itchy, blistering skin rash that affects persons
with celiac disease.
Gluten, a protein which
a. is found in wheat, rye, barley and possibly oats
b. may also be present in manufactured products such as medications, vitamins,
and lip balms.
Gluten-free diet, chiefly includes
a. cereals without wheat or barley malt
b. fruits and vegetables
c. meat, poultry, and fish
d. milk-based foods
e. potatoes, rice, corn, beans
Malabsorption, impaired ability to absorb nutrients, such as
a. carbohydrates
b. fat
c. protein
d. vitamins and minerals
Malnutrition, inadequate nutrition resulting from
a. inadequate or unbalanced diet
b. malabsorption
c. particular medical conditions
d. problems with digestion or absorption
Villi, microscopic finger-like projections that line the epithelium of the small intestine
through which nutrients are absorbed.
Overview of celiac disease
Resources consulted
 Canadian Celiac Association
 Canadian Society of Intestinal Research
 Celiac disease – sprue: PubMed Health
 Celiac Disease: Canadian Celiac Association
 Current Literature: Canadian Celiac Association
 Diagnosis of Gluten-Sensitive Enteropathy (Celiac Disease): Alberta Society of
Gastroenterologists and the Toward Optimized Practice Program
 National Digestive Diseases Information Clearinghouse
Celiac disease
1. is an incurable condition that can be successfully managed with a gluten-free diet
2. has numerous comorbidities, complications and associated conditions, which often
complicate the clinical picture
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3. is a common genetic disorder that
a. may or may not run in families
b. may develop at any point from infancy to late adulthood
4. is an autoimmune condition
a. the exact cause of which is unknown
b. responds to gluten by damaging or destroying villi in the small intestine, leading
to malabsorption which produces
i. malnutrition (CDHO Advisory)
ii. complications and associated conditions
5. causes malabsorption, which results in malnourishment regardless of the amount of
food consumed
6. is strongly associated with dermatitis herpetiformis
7. affects
a. persons in all parts of the world
b. about 1 in 133 persons in North America
c. about 1 in 56 persons who have gastrointestinal symptoms undiagnosed as
those of celiac disease
d. about 1 in 39 persons who have a second-degree relative (grandparent, aunt,
uncle, or cousin) with celiac disease
e. about 1 in 22 persons who have a first-degree relative (sibling, child, or parent)
with celiac disease
8. may be triggered into activity for the first time by events such as
a. childbirth
b. pregnancy
c. severe emotional stress
d. surgery
e. viral infection
9. is associated with symptoms that
a. vary from person to person
b. may involve parts of the body other than the digestive system
c. variously include
i. abdominal pain, bloating, gas, or indigestion
ii. appetite change, which may be increased or decreased
iii. constipation
iv. diarrhea, persistent or intermittent
v. lactose intolerance
1. common at initial diagnosis
2. normally disappears after the start of the gluten-free diet
vi. nausea and vomiting
vii. stools that float, are foul smelling, bloody, or appear fatty
viii. unexplained weight loss
d. result from the malabsorption of key nutrients
10. in children, is most commonly experienced as some combination of symptoms which
a. all reflect malabsorption during the years when nutrition is critical to the child’s
normal growth and development
b. include some combination of problems of
i. behaviour
1. irritability
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11.
12.
13.
14.
2. fussiness
ii. the gastrointestinal system, such as
1. abdominal bloating and pain
2. constipation
3. diarrhea
4. constipation
5. fatty or pale, foul-smelling stools
6. nausea
7. vomiting
iii. growth and development
1. delayed puberty
2. weight
a. gain below age norms
b. loss
3. height below age norms
4. failure to thrive in infants
iv. oral health, including
1. dental enamel defects
2. changes in tooth colour
appears less likely to cause digestive symptoms in adults in whom it may instead
produce one or more of the following
a. amenorrhea
b. anxiety (CDHO Advisory)
c. aphthous stomatitis
d. bone or joint pain
e. depression (CDHO Advisory)
f. fatigue
g. infertility or recurrent miscarriage
h. neurological effects such as tingling and numbness in the hands and feet
i. osteoporosis (CDHO Advisory)
j. rheumatoid arthritis (CDHO Advisory)
k. seizures
l. unexplained iron-deficiency anemia (CDHO Advisory)
even without symptoms, may cause long-term complications
lacks a complete explanation of why the symptomatology is so varied; factors with an
apparent role in when and how celiac disease appears include
a. age at which consumption of gluten-containing foods began
b. amount of gluten-containing foods consumed
c. degree of damage to the small intestine
d. diagnostic delay: the longer the period prior to diagnosis and the start of the
gluten-free diet, the greater is the likelihood of complications
e. duration of breastfeeding: longer durations are associated with later onset in
children
presents difficulty in diagnosis because it resembles other conditions including
a. anemia of iron-deficiency type caused by menstrual blood loss (CDHO Advisory)
b. chronic fatigue syndrome
c. diverticulitis (CDHO Advisory)
d. inflammatory bowel disease, including
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15.
16.
17.
18.
i. ulcerative colitis (CDHO Advisory)
ii. Crohn’s disease (CDHO Advisory)
e. intestinal infections
f. irritable bowel syndrome (CDHO Advisory)
is diagnosed with
a. blood tests for
i. albumin
ii. alkaline phosphatase, a measure of bone loss
iii. clotting factor abnormalities, such as increased prothrombin time
iv. cholesterol
v. complete blood count
vi. liver enzymes
b. endoscopy for biopsy of the duodenum to inspect the villi
c. genetic testing
is treated with
a. a rigorous gluten-free diet, the only definitive treatment, which
i. must be strictly maintained throughout the person’s life
ii. can heal existing damage
b. certain medications
cannot be prevented
a. because the exact cause is unknown
b. is most successfully managed with a combination of
i. awareness of risk factors
ii. early diagnosis
has an encouraging but mixed prognosis because
a. a gluten-free diet
i. repairs the damage to the intestines
ii. prevents further damage
iii. yields benefits for
1. children in 3 to 6 months
2. adults in 2 to 3 years
b. long-term damage is only rarely caused to the lining of the intestines before the
diagnosis is made
c. some problems may not improve, such as
i. below-norm height
ii. dental enamel defects
d. of the wide range of comorbidities, complications and associated conditions.
Overview of dermatitis herpetiformis
Resources consulted
 Dermatitis Herpetiformis: Canadian Celiac Association
 Dermatitis Herpetiformis: NIH
Dermatitis herpetiformis
1. is a chronic skin manifestation of celiac disease that
a. affects 10 percent or more of persons diagnosed with celiac disease
b. usually occurs in early to middle adult life but may also arise in children and
later adult life
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2. is characterized by
a. a blistered, itchy and burning rash that
i. may be present in the absence of classic intestinal symptoms of celiac
disease
ii. starts with 2-5 mm blisters which develop into erosions that
1. are most commonly symmetrically distributed on the elbows,
knees and buttocks
2. occasionally appear on the back of the neck, upper back, scalp,
hairline and face
b. recovery following the start of the gluten-free diet
3. is treated with dapsone as required for relief from burning and itching.
Food labelling
Questions and Answers About the New Regulations to Enhance the Labelling of Food
Allergens, Gluten and Added Sulphites: Health Canada
Multimedia and images
Dermatitis herpetiformis on the arm and legs
Dermatitis herpetiformis on the knee
Digestive system
Comorbidity, complications and associated conditions
Comorbid conditions are those which co-exist with celiac disease but which are not believed
to be caused by it. Complications and associated conditions are those that may have some
link with it. Distinguishing among comorbid conditions, complications and associated
conditions may be difficult in clinical practice.
Resources consulted
 AGA Institute Medical Position Statement on the Diagnosis and Management of
Celiac Disease
 Canadian Celiac Association
 Co-Morbidities: Canadian Celiac Association
1. Because celiac disease is an autoimmune disorder
a. other autoimmune conditions may be linked to it in some way; these include
i. autoimmune liver disease (CDHO Advisory)
ii. Down syndrome (CDHO Advisory)
iii. Graves’ disease (CDHO Advisory)
iv. myasthenia gravis
v. rheumatoid arthritis (CDHO Advisory)
vi. sarcoidosis
vii. Sjögren’s syndrome (CDHO Advisory)
viii. systemic lupus erythematosus (CDHO Advisory)
ix. type 1 diabetes (CDHO Advisory)
x. Turner syndrome
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2.
3.
4.
5.
b. other comorbid conditions include
i. Addison’s disease (CDHO Advisory)
ii. fatigue
iii. infertility
iv. liver disease (CDHO Advisory)
v. intestinal lymphoma
vi. neurological diseases
vii. shortness of stature
Other conditions or complications appear to occur when celiac disease is untreated, and
are expected to improve with a gluten-free diet; these include
a. osteoporosis (CDHO Advisory)
b. depression (CDHO Advisory)
c. anemia (CDHO Advisory)
d. deficiency of iron, folic acid and/or Vitamin B12
Complications and conditions associated with delayed diagnosis include
a. anemia (CDHO Advisory)
b. autoimmune disorders
c. bone disease
i. fractures
ii. kyphoscoliosis
iii. osteoporosis (CDHO Advisory)
d. hypoglycemia (CDHO Advisory)
e. infertility or repeated miscarriage
f. intestinal cancer
g. liver disease (CDHO Advisory)
Complications and conditions associated with malabsorption
a. anxiety (CDHO Advisory)
b. bruising tendency
c. depression (CDHO Advisory)
d. fatigue
e. growth delay in children
f. hair loss
g. itchy skin (dermatitis herpetiformis)
h. missed menstrual periods
i. mouth ulcers
j. muscle cramps and joint pain
k. nosebleeds
l. seizures
m. tingling or numbness in the hands or feet
n. unexplained below-norm height
Even without symptoms, celiac may cause long-term complications
a. anemia (CDHO Advisory)
b. intestinal cancer
c. liver disease (CDHO Advisory)
d. miscarriage
e. osteoporosis (CDHO Advisory)
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CDHO Advisory | Celiac Disease
Oral health considerations
Adapted from
 Dental Enamel Defects and Celiac Disease
1. Dental enamel defects
a. are one of the manifestations of celiac disease, though not all dental enamel
defects are caused by it
b. may for some persons be the only presenting sign or symptom of celiac disease
c. can help dental hygienists identify persons who may have celiac disease
d. associated with celiac disease involve the permanent dentition and include
i. tooth discoloration: white, yellow, or brown spots on the teeth
ii. poor enamel formation
iii. pitting or banding of teeth
iv. mottled or translucent-looking teeth
v. defects that are symmetrical and often appear on the incisors and
molars
vi. defects that do not improve once a diagnosed patient/client adopts a
gluten-free diet
e. appear to be strongly associated with celiac disease in childhood, likely during
enamel formation
f. may be confused with imperfections incorrectly ascribed, for example, to
i. early childhood illness
ii. excessive fluoride
iii. maternal illness
iv. maternal tetracycline
g. are disguised with cosmetic treatment, such as bonding and veneers
h. should be reported to the primary care physician.
2. Other oral manifestations include
a. recurrent aphthous stomatitis
b. atrophic glossitis
c. dry mouth syndrome
d. Sjögren’s syndrome (CDHO Advisory)
e. squamous carcinoma of the pharynx and mouth (CDHO Advisory).
3. Other oral health considerations include severe emotional stress as a trigger for celiac
disease.
MEDICATIONS SUMMARY
Sourcing medications information
1. Adverse effect database
 Health Canada’s Marketed Health Products Directorate
toll-free 1-866-234-2345
 Health Canada’s Drug Product Database
2. Specialized organizations
 US National Library of Medicine and the National Institutes of Health Medline Plus
Drug Information
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3. Medications considerations
All medications have potential side effects whether taken alone or in combination with
other prescription medications, or over-the-counter (OTC) or herbal medications.
4. Information on herbals and supplements
 US National Library of Medicine and the National Institutes of Health Medline Plus
Drug Information All Herbs and Supplements
Gluten is used in some medications.
Types of medications
A rigorous gluten-free diet is the only definitive treatment, which must be strictly
maintained throughout the rest of the person’s life, and which can repair existing damage.
1. dapsone (diaminodiphenylsulfone)
a. an antibiotic used to control the rash of dermatitis herpetiformis
b. does not treat the intestinal condition, so that persons with dermatitis
herpetiformis must maintain a gluten-free diet
2. vitamin and mineral supplements, as required
3. corticosteroids, as required
prednisone (Prednisone Intensol®)
Side effects of medications
See the links above to the specific medication.
THE MEDICAL AND MEDICATIONS HISTORY
The dental hygienist in taking the medical and medications history-taking should
1. focus on screening the patient/client prior to treatment decision relative to
a. key symptoms
b. medications considerations
c. contraindications
d. complications
e. comorbidities
f. associated conditions
2. explore the need for advice from the primary or specialized care provider(s)
3. inquire about
a. pointers in the history of significance to celiac disease, such as dental enamel
defects and other oral manifestations
b. symptoms indicative of comorbidities, complications and associated conditions
that should be taken into consideration in decisions about implementing the
Procedures
c. the patient/client’s understanding and acceptance of the need for oral
healthcare
d. medications considerations, including over-the-counter medications, herbals
and supplements
e. problems with previous dental/dental hygiene care
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f.
problems with infections generally and specifically associated with
dental/dental hygiene care
g. the patient/client’s current state of health
h. how the patient/client’s current symptoms relate to
i. oral health
ii. health generally
iii. recent changes in the patient/client’s condition.
IDENTIFYING AND CONTACTING THE MOST APPROPRIATE HEALTHCARE PROVIDER(S) FOR ADVICE
Identifying and contacting the most appropriate healthcare provider(s) from whom to obtain
medical or other advice pertinent to a particular patient/client
The dental hygienist should
1. record the name of the physician/primary care provider most closely associated with
the patient/client’s healthcare, and the telephone number
2. obtain from the patient/client or parent/guardian written, informed consent to contact
the identified physician/primary healthcare provider
3. use a consent/medical consultation form, and be prepared to fax the form to the
provider
4. include on the form a standardized statement of the Procedures proposed, with a
request for advice on proceeding or not at the particular time, and any precautions to
be observed.
UNDERSTANDING AND TAKING APPROPRIATE PRECAUTIONS
Infection Control
Dental hygienists are required to keep their practices current with infection control policies
and procedures, especially in relation to
1. the Recommendations published by the Centers for Disease Control and Prevention
(a frequently updated resource)
2. relevant occupational health and safety legislative requirements
3. relevant public health legislative requirements
4. best practices or other protocols specific to the medical condition of the patient/client.
DECIDING WHEN AND WHEN NOT TO INITIATE THE PROCEDURES PROPOSED
1. There is no contraindication to the Procedures.
2. With an otherwise healthy patient/client whose symptoms are under control and whose
treatment is proceeding normally, the dental hygienist should implement the
Procedures, though these may be postponed pending
a. medical advice, which is likely to be required if the patient/client
i. has symptoms or signs of exacerbation of celiac disease
ii. provides a history of comorbidity, complication or associated condition
of celiac disease that should be taken into account in decisions about
implementing the procedures
iii. has not complied with pre-medication, including antibiotic prophylaxis,
as directed by the prescribing physician
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iv. has not recently or ever sought and received medical advice relative to
oral healthcare procedures
v. has recently changed significant medications, under medical advice or
otherwise
vi. has recently experienced changes in his/her medical condition such as
medication or other side effects of treatment
vii. is unable to provide the dental hygienist with sufficient information
about
1. medications
2. bleeding tendency
3. treatment of comorbidity, complication or associated condition
viii. is deeply concerned about any aspect of his or her medical condition
b. a pharmacist’s advice if confirmation is required of the absence of gluten from
any medications required in the course of the proposed oral healthcare.
DEALING WITH ANY ADVERSE EVENTS ARISING DURING THE PROCEDURES
Dental hygienists are required to initiate emergency protocols as required by the College of
Dental Hygienists of Ontario’s Standards of Practice, and as appropriate for the condition of
the patient/client.
First-aid provisions and responses as required for current certification in first aid.
RECORD KEEPING
Subject to Ontario Regulation 9/08 Part III.1, Records, in particular S 12.1 (1) and (2) for a
patient/client with a history of celiac disease, the dental hygienist should specifically record
1. a summary of the medical and medications history
2. any advice received from the physician/primary care provider relative to the
patient/client’s condition
3. the decision made by the dental hygienist, with reasons
4. compliance with the precautions required
5. all Procedure(s) used
6. any advice given to the patient/client.
ADVISING THE PATIENT/CLIENT
The dental hygienists should
1. urge the patient/client to alert any healthcare professional who proposes any
intervention or test that he or she
a. has a history of celiac disease
b. is taking medication
2. should discuss with the patient/client, as appropriate
a. the risks of gluten in medications and preparations used for oral hygiene
self-care
b. the importance of the patient/client’s
i. self-checking the mouth regularly for new signs or symptoms
ii. reporting to the appropriate healthcare provider any changes in the
mouth
c. the need for regular oral health examinations and preventive oral healthcare
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d. oral self-care including information about
i. choice of toothpaste
ii. tooth-brushing techniques and related devices
iii. dental flossing
iv. mouth rinses
v. management of a dry mouth
e. the importance of
i. an appropriate diet in the maintenance of oral health
ii. help from a registered dietitian who specializes in celiac disease
f. comfort level while reclining, and stress and anxiety related to the Procedures
g. medication side effects such as dry mouth, and recommend treatment
h. mouth ulcers and other conditions of the mouth relating to celiac disease,
comorbidities, complications or associated conditions, medications or diet
i. pain management.
BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS
POTENTIAL BENEFITS
1. Promoting health through oral hygiene for persons who have celiac disease.
2. Reducing the adverse effects of overlooking celiac disease by
a. recognizing celiac disease at an early stage from dental enamel defects
b. ensuring that the medical history is appropriately recorded
c. generally increasing the comfort level of persons in the course of dental-hygiene
interventions
3. Reducing the risk that oral health needs are unmet.
POTENTIAL HARMS
1. Causing harm by failing to alert patients/clients to the possibility of gluten in the
medications they use for oral hygiene self-care.
2. Performing the Procedures at an inappropriate time, such as in the presence of
comorbidities, complications and associated conditions for which prior medical advice is
required.
3. Disturbing the normal dietary and medications routine of a person with celiac disease.
4. Inappropriate management of pain or medication.
CONTRAINDICATIONS
CONTRAINDICATIONS IN REGULATIONS
Identified in the Dental Hygiene Act, 1991 – O. Reg. 218/94 Part III
ORIGINALLY DEVELOPED
2009-11-24
DATE OF LAST REVIEW
2011-03-01
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ADVISORY DEVELOPER(S)
College of Dental Hygienists of Ontario, regulatory body
Greyhead Associates, medical information service specialists
SOURCE(S) OF FUNDING
College of Dental Hygienists of Ontario
ADVISORY COMMITTEE
College of Dental Hygienists of Ontario, Practice Advisors
COMPOSITION OF GROUP THAT AUTHORED THE ADVISORY
Dr Gordon Atherley
O StJ , MB ChB, DIH, MD, MFCM (Royal College of Physicians, UK), FFOM (Royal College of
Physicians, UK), FACOM (American College of Occupational Medicine), LLD (hc), FRSA
Lisa Taylor
RDH, BA, MEd
ACKNOWLEDGEMENTS
The College of Dental Hygienists of Ontario gratefully acknowledges the Template of
Guideline Attributes, on which this advisory is modelled, of The National Guideline
Clearinghouse™ (NGC), sponsored by the Agency for Healthcare Research and Quality
(AHRQ), U.S. Department of Health and Human Services.
Denise Lalande
Final layout and proofreading
COPYRIGHT STATEMENT
© 2009, 2011 College of Dental Hygienists of Ontario
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