Dental Maturity in Children With Celiac Disease

A Case-control Study

Najlaa M. Alamoudi; Farah A. Alsadat; Azza A. El-Housseiny; Osama M. Felemban; Amani A. Al Tuwirqi; Rana H. Mosli; Omar I. Saadah


BMC Oral Health. 2020;20(311) 

In This Article


The purpose of this study was to assess dental maturity (DM) in children with CD. The presence of delayed DM in children is an important consideration and of acute interest to pediatric dentists. It is regarded as a key clinical factor that should be examined to identify children with CD, separate to the presence of gastrointestinal symptoms, informing decision-making in suspected cases. Early recognition and diagnosis help in enabling prompt implementation of a gluten-free diet (GFD), which results in better treatment and militates against complications.[20,21]

Dental age (DA) can be assessed clinically—through the enumeration of erupted teeth, as well as radiographically, which has been the approach of the present study. The reported advantage of the clinical method was primarily economic, excluding the need for costly additional equipment. However, this may be considered a drawback, since dental eruption (DE) dates have a wide range that can depend on various environmental or dental factors, such as the existing space within the dental arches, early extraction of primary teeth, or periapical abscesses causing rarifaction of bone. By contrast, the reported advantages of the radiographic method are that it depends exclusively on the development of teeth, regardless of local or enviromental factors.[6] Accordingly, the Demirjian method is the recommended method for assessing DM in children in Saudi Arabia.[10]

Multiple studies reported DA in CD using the clinical assessment of DE.[9,22–24] By contrast, the current study assessed DA/DM radiographically. We found delayed DM in 62.5% of children in the CD group and 3% of children in the healthy control group. These findings are broadly in line with a number of previously published case–control studies,[9,20–24] where a range of 20–70% for children with CD vs. 7–20% for healthy controls were reported. The prevalence of delayed DA was similar in the present study to the findings of these two studies, using a similar methodology of assessing DA radiographically,[8,9] with a range from 56.7 to 70% in children with CD. However, the prevalence of delayed DM in our study varied from those studies in that DA was assessed clinically, by counting the number of erupted teeth,[9,22–24] with a range from 20 to 38% in children with CD. Greater prevalence of delayed DE has likewise been reported in CD patients than controls,[8] and was considered a significant oral manifestation of CD in the appraisals of several studies.[23,25,26]

The delayed DA in CD might be related to malnutrition and malabsorption of nutrients or vitamins necessary for dental development, and retarded growth, as reported in a number of studies.[8,9,20,22,27] This analysis is also supported by one study which showed that the adequate intake of carbohydrates and fruits in children helped to militate against delayed DE.[28]

The present study found an average delayed DM of about 8 months in the CD group and an average advanced DM of 7 months in the control group. This difference in DM in CD patients was broadly in line with that of an Italian study (6–7 months), although in that study there was a delay of only 1 month in the healthy controls.[21] However, variation of ± 6 months was considered a normal finding in another study.[22] With regard to delayed DE, 6 months delay was considred within a normal range in a study that found delayed DE of 1.4 years in CD children, and delay of less than one year in the control group.[24] However, another study considered delayed DE after eight months beyond the normal eruption time.[23] In our study, we calculated the mean difference between CA and DA to assess for dental maturity, as defined previously.[4,18] A difference of approximately 3 months was considered normal, and delayed or advanced dental maturity is within the standard range of 12 months, as broadly defined in the literature.[18] Some investigators, however, have considered a delay of one month to be a minimal delay.[20] These differences in definitions of delayed DA or DE might have led to a considerable variety of conclusions regarding CD.

To the best of our knowledge, a limited number of studies have evaluated dental maturity based on DA in children with CD.[23,29,30] Studies[23,29] are relatively old,[28] is not written in English, and[29] also contains few details regarding dental maturity. However, the study design used in these publications, in which a CD group and control group of healthy children are examined concurrently, helped in the present study in documenting abnormalities related to a CD group in comparison to a control group. Indeed, we found that children with CD had a greater likelihood of delayed DM in comparison with healthy controls. One key study, however, reported variation in DA among children with CD on a GFD, which could explain the effect of a GFD in reversing dental manifestations of CD.[20] Our healthy controls, by contrast, showed more advanced DM, in agreement with a study that reported advanced DA in a healthy population.[31]

A bivariate analysis was performed to determine factors which could influence DM. The effect of gender on tooth development has yielded inconsistent results in the literature. In the present study, boys in the control group had a more advanced DM, which constrast with the findings of some previous studies in normal children and in children with a cleft lip and palate.[10,27,32,33] Perhaps the difference in DM between genders is also related to genetic, hormonal, and envionmental factors.[5,27] Furthermore, a study from Italy has found no gender difference between children with delayed DA.[20] In the present study, the older age group in children with CD was associated with greater delayed DM, in contrast to the younger age group, similar to the findings of the aforementioned study of patients with a cleft lip and palate.[33]

Higher family income and higher maternal education were found to be a preventive factors for delayed DM, which may be a product of a presumably richer nutritional supply and a higher standard of dental care. Lower socioeconomic status, and particularly poverty, where families cannot afford appropriate and nutritious food, may affect the provision of a GFD; this was reported in relation to DE in one study.[28] Daily vegetable consumption in healthy controls was found to be a protective factor against delayed tooth maturity. Perhaps this was because controls may not have problems in their absorption of nutrients, specifically vitamin and minerals, present in vegetables. This was supported by a study that illustrated that the intake of vegeables helps in maturation of the masticatory apparatus, including teeth, used for chewing food.[28]

The present study may have some moderate limitations. Regular consumption of a GFD has been shown to enhance growth of teeth in the jawbones,[20] and found to have a constructive effect on increasing DM.[21] In the present study, we were not able to assess compliance with a GFD. Such data would have been better taken in a longitudinal study design, which we recommended to be carried out in future work. Indeed, this study has a cross-sectional nature, which makes us unable to determine a cause–effect relationship between variables. Another limitation of the food checklist is that this method is not representative of the exact amount of daily food intake.[34] Also, CD patients that were taking GHs were not excluded, since 19.7% of patients with CD had been found with a GH deficiency, requiring GH treatment, despite being on a GFD.[35] The main strength of this study is that it is perhaps the only recent study to determine effectively the significance of DM in children with CD.