Vol.:(0123456789)1 3 Clinical Oral Investigations (2023) 27:3579–3588 https://doi.org/10.1007/s00784-023-04971-x RESEARCH Nutrition and oral health in children with recently and previously diagnosed celiac disease M Bulut1   · M Tokuc1   · MN Aydin1   · H Ayyildiz Civan2   · E Polat3   · G Dogan4   · C Altuntas5   · NA Bayrak6   · OF Beser7  Received: 7 September 2022 / Accepted: 19 March 2023 / Published online: 24 March 2023 © The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2023 Abstract Objectives  To evaluate the nutritional and oral health status of children with previously diagnosed celiac disease (CD) who follow a gluten-free diet and recently diagnosed CD patients. Materials and methods  Previously and recently diagnosed groups were formed from children with CD, aged 4 to 15 years. A questionnaire was completed about the children’s dental history and nutritional and oral hygiene habits. All the children underwent an oral examination, and dmft-DMFT indices were determined. Dental plaque status, periodontal health, and dental enamel defects were recorded. Oral soft tissues were examined for the presence of lesions. Unstimulated salivary flow rate and pH value were evaluated. Results  A statistically significant difference was determined between the previously and recently diagnosed patients in terms of toothpaste preference (p=0.003), frequency of going to the dentist (p=0.039), and the types of dental treatment they had received (p=0.001). A statistically significant difference was determined between the previously and recently diagnosed patient groups in terms of dmft values (p=0.005). Conclusions  Children with CD should be directed to a pediatric dentist to improve oral and dental health, relieve the symp- toms of oral mucosal lesions, be informed about enamel defects, and be encouraged to use gluten-free oral care products. Clinical relevance  The collaboration of pediatric gastroenterologists and pediatric dentists can prevent the progression of oral symptoms in children with CD and eliminate long-term complications in terms of both oral health and multisystemic problems. Keywords  Celiac disease · Children · Oral health · Nutrition · Dental caries · Enamel defect * M Bulut cimenmg@gmail.com; muge.bulut@okan.edu.tr M Tokuc mugeyavas@outlook.com MN Aydin mervenuraydin89@gmail.com H Ayyildiz Civan hasretayyildiz@yahoo.com E Polat esrkcdr@gmail.com G Dogan guzidedogan@gmail.com C Altuntas cansu.altuntas@istinye.edu.tr NA Bayrak aykutbayrak@hotmail.com OF Beser ofbeser@gmail.com 1 Department of Pediatric Dentistry, Faculty of Dentistry, Istanbul Okan University, Istanbul, Türkiye 2 Pediatric Gastroenterology, Hepatology and Nutrition, I.A.U. VM Medical Park Hospital Florya, Istanbul, Türkiye 3 Pediatric Gastroenterology, Hepatology and Nutrition, Sancaktepe Sehit Prof Dr Ilhan Varank Training & Research Hospital, University of Health Sciences, Istanbul, Türkiye 4 Department of Pediatric Gastroenterology, Hepatology and Nutrition, Bezmialem Vakif University Faculty of Medicine, Istanbul, Türkiye 5 Department of Pediatric Gastroenterology, Hepatology and Nutrition, Istinye University Faculty of Medicine, Istanbul, Türkiye 6 Pediatric Gastroenterology, Hepatology and Nutrition, Zeynep Kamil Women & Children’s Training & Research Hospital, University of Health Sciences, Istanbul, Türkiye 7 Department of Paediatric Gastroenterology, Hepatology and Nutrition, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Türkiye http://crossmark.crossref.org/dialog/?doi=10.1007/s00784-023-04971-x&domain=pdf https://orcid.org/0000-0002-3088-7517 https://orcid.org/0000-0002-3933-9998 https://orcid.org/0000-0001-9388-8069 https://orcid.org/0000-0002-5604-9722 https://orcid.org/0000-0002-0185-0344 https://orcid.org/0000-0003-4291-7282 https://orcid.org/0000-0002-1161-5145 https://orcid.org/0000-0002-5553-6123 https://orcid.org/0000-0003-1927-7256 3580 Clinical Oral Investigations (2023) 27:3579–3588 1 3 Introduction Celiac disease (CD) is an autoimmune chronic disease that develops in individuals who are genetically sensitive to gluten, a protein found in wheat, rye, and barley, which leads to widespread villous atrophy and lymphocyte infil- tration of the small intestinal mucosa due to persistent intolerance to polypeptide fragments of this protein [1–3]. People with HLA class II DQ2 and DQ8 haplotypes are known to have an increased risk of developing the disease [4]. Although the incidence of CD varies between 0.3 and 1% in Türkiye, it is estimated that there are approximately 700,000 as yet undiagnosed celiac patients [5]. The diagnosis of CD is made from serological tests, small intestinal biopsy, and genetic tests [6]. Recent research has redefined the many forms of CD. In classical CD, patients show typical signs and gastrointestinal symp- toms, such as chronic diarrhea, abdominal pain, bloating, weight loss, constipation, peptic ulcer, and reflux. In the non-classical type of CD, patients may show mild gastro- intestinal symptoms that do not indicate a clear malabsorp- tion or signs and symptoms that may be confused with other chronic diseases (e.g., folic acid and B12 deficiency, iron-deficiency anemia, chronic fatigue, chronic migraine) [7]. However, latent and potential CD are both described as a normal small intestinal biopsy result in an individ- ual with positive serology, while silent CD is known as asymptomatic CD and patients do not show any symptoms despite villous atrophy. The diagnosis is challenging in non-classical and silent CD and can be delayed particu- larly in children from low-income families with limited access to serological testing and biopsies [8–11]. As in other systemic diseases such as Sjögren’s syn- drome, type 1 diabetes mellitus, and Crohn’s disease, many oral symptoms are encountered in CD [12]. Con- sidering that these oral symptoms may indicate CD, it is critical for pediatric dentists to know and recognize the intraoral changes specific to CD and to refer their patients to a pediatric gastroenterologist for early and definitive diagnosis with serological tests/biopsy/genetic tests [2, 13]. Alsadat et al. reported that enamel defects may be the only symptoms of silent CD and this awareness can help in diagnosing the CD [10]. In literature, recurrent aphthous stomatitis (RAS), delayed tooth eruption, car- ies, geographic tongue, angular cheilitis, atrophic glossitis, burning tongue, dry mouth, and dental enamel abnormali- ties are oral manifestations associated with CD [2, 14]. In untreated CD patients, the clinical condition may be accompanied by dermatitis herpetiformis, anemia, delayed puberty, infertility, depression, epilepsy, decreased bone density, osteopenia/osteoporosis, and gluten-dependent serum diabetes mellitus. Complications related to CD can be prevented by detecting the disease in early childhood and starting a strict gluten-free diet [15]. Following a diag- nosis of CD, if a gluten-free diet is followed regularly, especially in childhood, intestinal lesions regress, and optimal growth and bone mineral density increase are sup- ported. In addition, good adherence to a gluten-free diet may provide a decrease in or elimination of all CD-related findings and normalization of specific CD antibodies [16]. It has been reported that oral mucosal lesions improve and the frequency of lesions decreases with regular follow-up of the gluten-free diet. It was also stated that the incidence of dental defects decreased with early diagnosis and treat- ment [10, 17]. Although there are many studies which have examined oral-dental results in celiac patients, there are gaps in the literature on the effect of the treatment and time of diagno- sis on the patient’s oral health. The aim of this study was to compare the oral health of previously diagnosed CD patients who follow a gluten-free diet with recently diagnosed CD patients and to identify intraoral alterations specific to CD. Within the scope of this study, the nutritional and oral hygiene habits of previously and recently diagnosed CD patients were questioned, and their dental and periodontal health and salivary characteristics were evaluated through intraoral examination. Methods The protocol of this clinical study was approved by the Clin- ical Ethics Committee of Marmara University (Decision no: 2019-276), and the study was conducted in accordance with the principles of the World Medical Association Declaration of Helsinki. The study included patients aged 4–15 years with a diag- nosis of CD. The diagnosis of CD of the patients was made by a pediatric gastroenterologist after positive tissue trans- glutaminase (tTG) IgA test and a small intestinal biopsy. Patients with a chronic systemic disease other than CD or who used medications related to a systemic disease were excluded from the study. Two study groups were formed: (a) previously diagnosed and (b) recently diagnosed. The previously diagnosed group included patients who had been diagnosed with CD at least 6 months previously and had followed a strict gluten-free diet for at least 6 months. The previously diagnosed celiac patients were called by their gastroenterologist for follow- up and to determine whether they adhered to their diets. The tTG IgA value was used to determine if the patients followed a gluten-free diet, and 52 patients with tTG IgA values within the normal range (defined as 0–20 Ru/ml) were included. The recently diagnosed group consisted of 26 patients with CD. The patients were diagnosed by 3581Clinical Oral Investigations (2023) 27:3579–3588 1 3 performing a small intestinal biopsy after the tTG IgA lev- els were determined to be at least 5-fold higher than the normal range. These patients, recently diagnosed with CD, were invited for oral examination to be included in the study before starting a gluten-free diet. The parents of the patients were contacted by telephone, and brief information was given about the study. Patients who volunteered to participate were invited to the pediatric dental clinic for oral examination. The parents of the patients referred to the clinic were given detailed information about the study, and oral and written consent was obtained. Before the clinical examination, the parents completed a question- naire to collect information about their child’s dental history, nutrition, and tooth brushing habits. Oral examination Intraoral examination of the patients was performed by a sin- gle experienced pediatric dentist (M.B.) with 9 years of den- tal clinical experience. The physician performed a calibra- tion study for the detection of dental caries according to the WHO criteria before the study, and intra-examiner reliability was assessed using Kappa analysis. Kappa values for intra- examiner reliability for the dmft and DMFT indices were 0.92 and 0.93, respectively. These results indicated good agreement. Before the intraoral examination, panoramic radiography was taken from the patient within the indication. The decayed, missing, and filled teeth were determined for both primary (dmft index) and permanent dentition (DMFT index) [18]. Dental plaque status and periodontal health were recorded according to the Silness and Löe score system [19]. The presence of dental enamel defects in primary and permanent teeth was evaluated according to the Aine’s clas- sification [20]. Soft tissue surfaces were examined for the presence of RAS and other mucosal lesions. In addition, the history and frequency of encountering aphthous stomatitis of the patients were questioned. The oral examination was performed under standard conditions on a dental chair with light using air-water spray and a blunt-tipped probe. Salivary parameters Unstimulated saliva samples were collected from the patients for evaluation of pH and flow rate. The patients were instructed to refrain from eating, drinking, or chewing gum for 1 h before the oral examination. Before starting to collect saliva, the patients rinsed their mouth with water. The patients were seated in the dental chair with their eyes open, head tilted slightly forward, and in an upright posi- tion. Following the first swallow, they were instructed to spit all the saliva present in the mouth every 30 s for 2 min. This procedure was carried out under the supervision of the patient’s parent and the physician using a stopwatch. The unstimulated salivary flow rate was calculated by dividing the collected saliva volume in the graduated test tube by the sample collection time. The salivary pH was measured by dipping the buffering strip (Colorkim, Istanbul, Türkiye) into the test tube in accordance with the manufacturer’s instructions. Statistical analysis Data obtained in the study were analyzed statistically using the IBM Statistical Package for the Social Sciences (SPSS) software (version 21.0, IBM Corp., Armonk, NY, USA). Descriptive statistics for each variable were calculated and expressed as mean ± standard deviation (SD) or median (Q1–Q3) values for continuous variables and as number (n) and percentage (%) for categorical variables. The data were assessed for conformity to normal distribution with the Sha- piro-Wilk test prior to hypothesis testing. The Mann-Whit- ney U-test was used to compare the groups as parametric test assumptions were not met. The Pearson chi-square test was used to examine the frequency distribution for categorical variables. When >20% of expected counts were <5 for RxC tables, Fisher-Freeman-Halton tests were employed. In all statistical analyses, the level of statistical significance was set at p<0.05. Results This study included 52 children with previously diagnosed CD with a mean age of 9.35±2.98 years and 26 children with recently diagnosed CD with a mean age of 8.12±3.23 years. The comparisons of the questionnaire responses accord- ing to previously and recently diagnosed patients are pre- sented in Table 1. A statistically significant difference was determined between the previously and recently diagnosed patients in terms of the toothpaste preference, the frequency of going to the dentist, and the types of dental treatment they had received. The rate of recently diagnosed patients who preferred fluoride-free toothpaste was significantly higher than the previously diagnosed patients (p=0.003). The previ- ously diagnosed patients visited a dentist at a significantly higher rate than the recently diagnosed patients (p=0.039). Filling and tooth extraction treatments were performed more in the previously diagnosed patient group. The proportion of those who had not received any dental treatment was sig- nificantly higher in the recently diagnosed group (p=0.001). There was no statistically significant difference between the patient groups in respect of the other questionnaire responses (p>0.05). The unstimulated salivary flow rate, gingival index, and plaque index values of the previously and recently diag- nosed patients were compared (Table 2), and no statistical 3582 Clinical Oral Investigations (2023) 27:3579–3588 1 3 Table 1   Comparisons of the answers given to the questionnaire according to the groups of previously and recently diagnosed patients Previously (n=52) Recently (n=26) p n n (%) n n (%) Gender Boys 22 42.30% 9 34.60% 0.683 Girls 30 57.70% 17 65.40% Tooth brushing frequency Twice a day 22 42.30% 11 42.30% 1 Once a day 15 28.80% 7 26.90% Every other day 2 3.80% 1 3.80% Very rarely 13 25% 7 26.90% Using toothpaste while brushing Yes 43 82.70% 20 76.90% 0.761 No 9 17.30% 6 23.10% Toothpaste preference With fluoride 23 44.2%a 6 23.1%a *0.003 Fluoride free 1 1.9%a 7 26.9%b Gluten free 19 36.5%a 7 26.9%a Do not know 9 17.3%a 6 23.1%a Brushing teeth before bedtime Yes 21 40.40% 10 38.50% 1 No 31 59.60% 16 61.50% Frequency of changing toothbrush 0–3 months 17 32.70% 14 56% 0.059 4–6 months 27 51.90% 5 20% 7–9 months 6 11.50% 4 16% 10–12 months 2 3.80% 2 8% Using dental floss/interdental brush No 45 88.20% 22 84.60% 0.51 Very rarely 6 11.80% 3 11.50% Often 0 0 1 3.80% Gingival bleeding while brushing teeth No 25 48.10% 16 61.50% 0.426 Very rarely 21 40.40% 9 34.60% Often 6 11.50% 1 3.80% Dry mouth complaint No 27 51.90% 16 61.50% 0.479 Very rarely 19 36.50% 6 23.10% Often 6 11.50% 4 15.40% Frequency of going to the dentist Every 6 months 10 19.2%a 1 3.8%a *0.039 Once a year 6 11.5%a 2 7.7%a Only when in pain 17 32.7%a 5 19.2%a None 19 36.5%a 18 69.2%b Dental treatments Filling 17 32.7%a 1 3.8%b *0.001 Gingival treatment 3 5.8%a 1 3.8%a Root canal treatment 4 7.7%a 0 0a Fissure sealant and fluor 3 5.8%a 1 1%a Tooth extraction 14 26.9%a 2 7.7%b None 25 48.1%a 21 80.8%b Carbohydrate intake Never 7 13.50% 4 15.40% 0.731 Once a day 28 53.80% 11 42.30% 1–3 times a day 14 26.90% 8 30.80% More than 3 times a day 3 5.80% 3 11.50% Sugary drink intake Never 15 28.80% 13 50% 0.243 Once a day 28 53.80% 8 30.80% 1–3 times a day 8 15.40% 4 15.40% More than 3 times a day 1 1.90% 1 3.80% Eating late at night Yes 16 30.80% 9 34.60% 0.932 No 36 69.20% 17 65.40% 3583Clinical Oral Investigations (2023) 27:3579–3588 1 3 difference was determined between the patient groups (p>0.05). The dmft values were determined to be statistically sig- nificantly different in the previously and recently diagnosed patient groups (Table 3). The dmft values of the previously diagnosed patients were significantly higher (p=0.005). There was no significant difference between the groups in terms of other quantitative variables (p>0.05). Table 1   (continued) Previously (n=52) Recently (n=26) p n n (%) n n (%) Snacking between meals Never 9 17.30% 0 0 0.057 Once a day 24 46.20% 19 73.10% 1–3 times a day 14 26.90% 5 19.20% More than 3 times a day 5 9.60% 2 7.70% Vegetable, fruit intake Never 2 3.80% 2 7.70% 0.879 Once a day 23 44.20% 12 46.20% 1–3 times a day 20 38.50% 9 34.60% More than 3 times a day 7 13.50% 3 11.50% Milk and dairy products intake Never 4 7.70% 3 11.50% 0.936 Once a day 35 67.30% 16 61.50% 1–3 times a day 11 21.20% 6 23.10% More than 3 times a day 2 3.80% 1 3.80% *Statistical significance difference p<0.05 a,b Each subscript letter for each variable denotes a subset of “patient type” categories whose column pro- portions do not differ significantly from each other at the 0.05 level Table 2   Comparisons of unstimulated salivary flow rate, gingival index, and plaque index values of the previously and recently diagnosed patients Previously (n=52) Recently (n=26) P n n (%) n n (%) Unstimulated saliva flow rate Hyposalivation 6 11.50% 5 19.20% 0.563 Low 14 26.90% 5 19.20% Normal 32 61.50% 16 61.50% Gingival index 0-Normal gingiva 32 61.50% 19 73.10% 0.108 1-Mild inflammation 12 23.10% 7 26.90% 2-Moderate inflammation 8 15.40% 0 0 3-Severe inflammation 0 0 0 0 Plaque index 0-Absence of plaque 27 51.90% 17 65.40% 0.668 1-Plaque detected with probe 13 25% 5 19.20% 2-Visible plaque 8 15.40% 2 7.70% 3-Abundant plaque 4 7.70% 2 7.70% Table 3   Comparisons of quantitative variables according to the previously and recently diagnosed patients *Statistical significance difference p<0.05 Previously (n=52) Recently (n=26) Mean ± standard deviation (SD) Median (Q1–Q3) Mean ± standard deviation (SD) Median (Q1–Q3) p Age 9.35±2.98 9 (7–11.5) 8.12±3.23 8 (5–10) 0.124 DMFT 3.17±3.3 3 (0–4) 1.59±2.06 0 (0–3) 0.065 dmft 3.92±3.17 3 (1.5–6) 1.96±2.74 0 (0–4) *0.005 Saliva pH 7.19±0.49 7 (7–7) 7.19±0.4 7 (7–7) 0.943 3584 Clinical Oral Investigations (2023) 27:3579–3588 1 3 The presence or history of aphthous stomatitis was pre- sent in 19.2% of the recently diagnosed celiac patients and in 15.4% of the previously diagnosed celiac patient group. According to the Aine’s classification, 23% of the previ- ously diagnosed patients had grade 1 enamel defects, 3.8% had grade 2 enamel defects, and 11.5% of the recently diag- nosed patients had grade 1 enamel defects. Discussion Many systemic disorders first manifest as oral symptoms as the starting point of the gastrointestinal tract is the oral cavity. CD is one of the chronic diseases that are reported to show various findings in the oral cavity [2]. In the treatment of CD, the patient is advised to follow a strict gluten-free diet, and it is recommended to check the patient’s compli- ance with the diet for 3–6 months using serum antibody con- centrations [21]. With strict adherence to the diet, a regres- sion in disease-related signs and symptoms can be observed, with improvement in serological tests in a minimum of 6 months [22, 23]. The aim of this study was to evaluate intraoral findings specific to celiac patients and compare the oral and den- tal health of recently diagnosed celiac patients with celiac patients treated with a gluten-free diet. In line with the lit- erature, the previously diagnosed patient group was formed from patients who strictly followed their diet for 6 months and had normal serological test results [21–24]. To assess the oral health status of the two groups, the nutritional and oral hygiene habits, dental and periodontal health status, and salivary characteristics were evaluated, and the subject was discussed in a comprehensive way. There was no difference in oral hygiene habits between the two patient groups in terms of the responses to the ques- tions about teeth brushing habits, using toothpaste and dental floss/interdental brush, and changing the toothbrush regularly. However, the rate of going to the dentist and hav- ing dental treatment was seen to be higher in the previously diagnosed patient group. The rate of using fluoride tooth- paste for tooth brushing was also higher in the previously diagnosed patients. When these responses were evaluated together with the intraoral examination findings, it was seen that previously diagnosed patients consulted the dentist more frequently due to the higher rate of caries experienced in their primary teeth. It was also thought that the higher rate of using fluoride toothpaste in this patient group was due to recommendation by the dentist. There is also gluten contamination in oral hygiene prod- ucts such as toothpastes and mouthwashes, and as these can be accidentally swallowed, this make them a potential source of gluten [25]. There is a lack of studies about the level of gluten contamination in oral care products and the safety of these products for celiac patients. Verma et al. reported that the gluten content of the toothpastes in the Italian mar- ket is insignificant and not an issue for celiac patients [26]. However, that study covered only the Italian market, and there is a lack of information in the literature about the glu- ten content of the oral care products in Türkiye. Therefore, ingestion of oral care products should be considered, and patients should be informed about the gluten content of these products. According to the results of this study, only 26 of 78 celiac patients reported using gluten-free toothpaste, and there was no difference in the use of gluten-free toothpaste between the previously and recently diagnosed patients. This result shows that the previously diagnosed patients had not been given sufficient information about the gluten content of toothpaste. It is thought that it would be beneficial to direct the patients with CD to the dentist for information about the gluten content of both toothpastes and oral care products. Diet plays an important role in preventing oral diseases such as dental caries, developmental defects, oral mucosal diseases, and periodontal diseases. Irregular nutrition and imbalances in the consumption of food groups adversely affect oral and dental health [27]. Ogata et al. reported that the consumption of sugary drinks, sweets, and fast food by children has been associated with reduced consumption of vegetables, fruits, and milk, and increased intake of sugary drinks can cause dental caries [28]. The type and frequency of food and drink consumed has a direct effect on oral pH and microbial activity, which can increase tooth decay. Excessive and irregular consumption of fermentable carbo- hydrates, insufficient consumption of cariostatic (eggs, fish, vegetables and oils, etc.), and anticariogenic food groups (foods containing casein, calcium, and phosphorus) are risk factors for the development of dental caries [27]. With a diagnosis of CD, the patient should be started on a strict gluten-free diet and the type of food consumed, the amount and frequency of consumption should be kept under control [29]. In a gluten-free diet, carbohydrate intake should be reduced significantly, there should be very lim- ited consumption of processed food, and the consumption of vegetables, fruits, and protein sources should be increased. As an outcome of the treatment with a gluten-free diet, it was thought that the awareness of the patients about nutri- tion would increase and accordingly they could form healthy and regular eating habits. Therefore, in this study, the eating habits of the previously and recently diagnosed CD patients were questioned. The study results showed no difference between the groups in the frequency of consumption of fer- mented food group such as carbohydrates, sugary drinks, and snacks. There was also observed to be no difference in the frequency of consumption of fruits and vegetables, milk, and dairy products. From these results, it has been concluded that previously diagnosed patients treated with a gluten-free diet do not change their eating habits to a diet 3585Clinical Oral Investigations (2023) 27:3579–3588 1 3 that is regular, low in fermented carbohydrates, and pre- dominantly composed of the anticariogenic and cariostatic food groups, which can have a positive effect on their oral and dental health [28, 29]. In a previous study conducted on children with CD, it was similarly observed that there was no difference in dietary habits between healthy children and children with CD [10]. When the children with CD in this study were evaluated according to the Silness and Löe gingival index and plaque index [19], they were seen to have mostly normal perio- dontal health, with a small percentage of mild to moderate inflammation of the gingiva. Severe inflammation was not observed in any of the patients. In addition, it was deter- mined that the time of diagnosis did not improve the perio- dontal and dental plaque status of the patient. This result was supported by the similar answers given to the questionnaire to determine periodontal health, such as brushing habits, gingival bleeding while brushing, and use of dental floss/ interface brush. All of these explain the very low number of children in both groups who needed gingival treatment. When reviewed in the literature, Tsami et al. evaluated the periodontal status of 35 celiac patients aged 4–18 years and stated that the patients needed periodontal treatment, but nutrition and other oral hygiene habits were not analyzed in that study. In addition, the oral hygiene level and periodontal status of the celiac children in that study were reported to be similar to those of the healthy population [30]. Oral and dental health is known to be directly related to salivary glands, salivary flow rate, and pH. As in many diseases, it is thought that some of the oral symptoms in CD are caused by the salivary glands being affected [31, 32]. In studies conducted by Dane and Gürbüz on 35 celiac and 35 healthy Turkish children, no difference was found between pH values, and it was stated that the values were within the normal range [33]. In contrast, Lahteenoja et al. reported that people with CD frequently have xerostomia [34]. There are also studies that have shown a decrease in stimulated salivary flow rates in children with CD com- pared to healthy children [33, 35]. However, Acar et al. reported normal stimulated salivary flow rate in 54.3% of healthy children and 34.3% of children with CD and a salivary pH of 7.3 in healthy children and 7.5 in children with CD, with no significant difference reported between the two groups [36]. Similarly, Shteyer et al. examined 3 groups of children in 2013 and reported no difference in salivary pH between recently diagnosed celiac patients, previously diagnosed celiac patients on a gluten-free diet, and healthy control groups [24]. In the present study, the flow rate and pH values obtained from unstimulated saliva samples of the previously and recently diagnosed patients showed similar results. Salivary pH was determined as 7.1 in both previously and recently diagnosed patients, and normal salivary flow rate was determined in 61.50% of both the previously and recently diagnosed patients. In the responses of the previously and recently diagnosed patients to the question about dry mouth, no significant difference was seen between the complaints of the two patient groups. According to these results, it was con- cluded that no disease-specific findings were detected in the salivary characteristics of the celiac patients included in the study. Numerous epidemiological and clinical studies examin- ing the relationship between CD and dental caries in the pediatric population have revealed contradictory results [37–41]. Patients with CD and control groups consisting of healthy individuals were compared in these studies, with some researchers finding no difference between the celiac patients and the control group [10, 36] and others report- ing that the caries index was higher in the control groups [41, 42]. Contrary to these findings, Costacurta et al. found that celiac patients had a higher rate of caries [14]. How- ever, in these studies, no research was conducted on when the patients were diagnosed with CD and whether they fol- lowed their diets. In addition, although Acar et al. reported decreased levels of caries-causing bacteria (Streptococcus mutans, Lactobacillus) in the saliva of individuals with CD [36], Shteyer et al. rejected these findings [24]. In the current study, a greater number of decayed, filled, and extracted teeth were found in the deciduous teeth of previ- ously diagnosed patients compared to recently diagnosed patients, while no difference was observed in respect of the permanent teeth. The multifactorial nature of dental caries could explain these different results in previous studies. The variable results could also be attributed to age distribution differences, the follow-up status of the gluten-free diets, and differences in the nutritional and oral hygiene habits of the patient groups included in these studies. Oral findings due to systemic diseases in children are important for pediatric dentists in terms of aiding early diag- nosis of the disease. Therefore, attention should be paid to atypical changes in the oral cavity. Enamel defects are con- sidered a specific finding among the atypical findings of CD [43, 44]. It has been suggested that enamel defects in celiac patients may be due to changes in phosphate calcium metab- olism, a gluten-induced immune process that impairs enamel development, or an increased amount of HLA-DR3 antigen [45–47]. Many studies in the literature have indicated that structural changes of tooth enamel in CD can be used to diagnose CD [13, 43, 48, 49]. In the current study, enamel defects were not observed in all celiac patients. According to the Aine’s classification, only 34.5% of the celiac patients had grade 1 enamel defects, and 3.8% had grade 2 enamel defects. Therefore, it was concluded that the detected enamel defects were not sufficient to reach a conclusion about the relationship with CD. It was thought that longer-term studies are needed to investigate enamel changes in celiac patients. 3586 Clinical Oral Investigations (2023) 27:3579–3588 1 3 The age at which the disease is diagnosed is thought to affect the incidence of enamel defects [32, 41, 42, 50]. Cheng et al. reported a higher rate of enamel defects in chil- dren and adolescents in the mixed dentition compared to the permanent dentition, which may have been due to the development of CD after the mineralization of the dental crowns [49]. Similarly, Aine et al. reported the diagnosis of CD before the age of 6 years, when the mineralization of the crowns of the permanent teeth is completed, and the transi- tion to a gluten-free diet prevents the formation of enamel defects in the permanent teeth [20]. It is thought that the low average age of the patients in the study and the diagnosis of CD in early childhood decreased the rate of enamel defects. One of the other complications observed in the oral cav- ity in celiac patients is intramucosal disorders, particularly RAS [44, 51, 52]. Although the etiology of RAS is not fully known, it is thought that a number of factors such as genetic, immunological and microbial factors, endocrine disorders, and malnutrition may play a role in the etiology. It has been suggested that iron, folic acid, and vitamin B12 deficiencies, which are also frequently observed in celiac patients, may cause RAS [34, 53]. Several studies have reported that chil- dren with CD often have aphthous ulcers, and these lesions show significant improvement after starting a gluten-free diet [17, 44, 51, 53]. In this study, the presence or a history of RAS was also observed in both the previously (15.4%) and recently diagnosed (19.2%) celiac patients. A limitation of this study is that the study groups included children with primary and mixed dentition who had not com- pleted their permanent dentition. As there was no long-term follow-up of the patients in this study, it should be consid- ered that some intraoral findings of CD may develop in these patients in the future. Longer-term studies are needed to investigate CD-specific findings in the oral cavity. Consider- ing the low incidence of CD and the potentially high number of undiagnosed patients in Türkiye, a total of 78 patients from 5 different centers were eligible for inclusion in this study, and age distribution was not taken into account while forming the groups. This may have also constituted a limita- tion for the data obtained from the dmft and DMFT indices. Children with CD should be directed to a pediatric dentist to relieve the symptoms caused by oral mucosal lesions, to be informed about enamel defects, and to be encouraged to use gluten-free oral care products. In this way, when patients follow a gluten-free diet under the supervision of pediatric gastroenterologists, there will be positive effects on their growth and development, and they will be able to maintain a high quality of life as healthy individuals with the oral hygiene training they receive during regular pediatric dentist visits. Availability of data and materials  The data presented and analyzed in the study are available from the corresponding author on request. Author contribution  • Müge Bulut: conceptualization, methodology, investigation, writing—reviewing and editing, original draft prepara- tion, supervision, visualization, project administration • Müge Tokuc: conceptualization, investigation, methodology, writing—reviewing and editing, writing—original draft preparation, project administration • Merve Nur Aydin: methodology, investigation • Hasret Ayyildiz Civan: methodology, investigation • Esra Polat: methodology, investigation • Guzide Dogan: methodology, investigation • Cansu Altuntas: methodology, investigation • Nevzat Aykut Bayrak: methodology, investigation • Omer Faruk Beser: conceptualization, methodology, reviewing and editing Declarations  Ethical approval  Approval for this study was granted by the Clinical Ethics Committee of Marmara University (Decision no: 2019-276). Competing interests  The authors declare no competing interests. References 1. Bai JC, Fried M, Corazza GR, Schuppan D, Farthing M, Catassi C et  al (2013) World Gastroenterology Organisation global guidelines on celiac disease. J Clin Gastroenterol 47(2):121–126. https://​doi.​org/​10.​1097/​MCG.​0b013​e3182​7a6f83 2. Macho VMP, Coelho AS, Veloso ESDM, de Andrade DJC (2017) Oral manifestations in pediatric patients with coeliac disease - a review article. Open Dent J 11:539–545. https://​doi.​org/​10.​2174/​ 18742​10601​71101​0539 3. Hill ID, Dirks MH, Liptak GS, Colletti RB, Fasano A, Guandalini S et al (2005) Guideline for the diagnosis and treatment of celiac disease in children: recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition. J Pediatr Gastroenterol Nutr 40(1):1–19. https://​doi.​org/​10.​1097/​ 00005​176-​20050​1000-​00001 4. Husby S, Koletzko S, Korponay-Szabo IR, Mearin ML, Phillips A, Shamir R et al (2012) European Society for Pediatric Gastro- enterology, Hepatology, and Nutrition guidelines for the diagnosis of coeliac disease. J Pediatr Gastroenterol Nutr 54(1):136–160. https://​doi.​org/​10.​1097/​MPG.​0b013​e3182​1a23d0 5. Republic of Turkey Ministry of Agriculture and Forestry Gen- eral Directorate of Food and Control. Parliamentary Investigation Commission Celiac Report. 2018. Available from: https://​www.​ tbmm.​gov.​tr/​siras​ayi/​donem​26/​yil01/​ss554.​pdf. 6. Lebwohl B, Rubio-Tapia A (2021) Epidemiology, presentation, and diagnosis of celiac disease. Gastroenterology 160(1):63–75. https://​doi.​org/​10.​1053/j.​gastro.​2020.​06.​098 7. Ludvigsson JF, Leffler DA, Bai JC, Biagi F, Fasano A, Green PH et al (2013) The Oslo definitions for coeliac disease and related terms. Gut 62(1):43–52. https://​doi.​org/​10.​1136/​ gutjnl-​2011-​301346 8. Troncone R, Greco L, Mayer M, Paparo F, Caputo N, Micillo M et al (1996) Latent and potential coeliac disease. Acta Paediatr Suppl 412:10–14. https://​doi.​org/​10.​1111/j.​1651-​2227.​1996.​tb142​ 40.x 9. Volta U, Caio G, Giancola F, Rhoden KJ, Ruggeri E, Boschetti E et al (2016) Features and progression of potential celiac disease in adults. Clin Gastroenterol Hepatol 14(5):686–693.e1. https://​ doi.​org/​10.​1016/j.​cgh.​2015.​10.​024 https://doi.org/10.1097/MCG.0b013e31827a6f83 https://doi.org/10.2174/1874210601711010539 https://doi.org/10.2174/1874210601711010539 https://doi.org/10.1097/00005176-200501000-00001 https://doi.org/10.1097/00005176-200501000-00001 https://doi.org/10.1097/MPG.0b013e31821a23d0 https://www.tbmm.gov.tr/sirasayi/donem26/yil01/ss554.pdf https://www.tbmm.gov.tr/sirasayi/donem26/yil01/ss554.pdf https://doi.org/10.1053/j.gastro.2020.06.098 https://doi.org/10.1136/gutjnl-2011-301346 https://doi.org/10.1136/gutjnl-2011-301346 https://doi.org/10.1111/j.1651-2227.1996.tb14240.x https://doi.org/10.1111/j.1651-2227.1996.tb14240.x https://doi.org/10.1016/j.cgh.2015.10.024 https://doi.org/10.1016/j.cgh.2015.10.024 3587Clinical Oral Investigations (2023) 27:3579–3588 1 3 10. Alsadat FA, Alamoudi NM, El-Housseiny AA, Felemban OM, Dardeer FM, Saadah OI (2021) Oral and dental manifestations of celiac disease in children: a case-control study. BMC Oral Health 21(1):669. https://​doi.​org/​10.​1186/​s12903-​021-​01976-4 11. Pinto-Sanchez MI, Silvester JA, Lebwohl B, Leffler DA, Ander- son RP, Therrien A et al (2021) Society for the Study of Celiac Disease position statement on gaps and opportunities in coeliac disease. Nat Rev Gastroenterol Hepatol 18(12):875–884. https://​ doi.​org/​10.​1038/​s41575-​021-​00511-8 12. Julkunen A, Heikkinen AM, Soder B, Soder PO, Toppila-Salmi S, Meurman JH (2017) Autoimmune diseases and oral health: 30-year follow-up of a Swedish cohort. Dent J 6(1). https://​doi.​ org/​10.​3390/​dj601​0001 13. Bossu M, Bartoli A, Orsini G, Luppino E, Polimeni A (2007) Enamel hypoplasia in coeliac children: a potential clinical marker of early diagnosis. Eur J Paediatr Dent 8(1):31–37 14. Costacurta M, Maturo P, Bartolino M, Docimo R (2010) Oral manifestations of coeliac disease.: a clinical-statistic study. Oral Implantol 3(1):12–19 15. Mearin ML, Ivarsson A, Dickey W (2005) Coeliac disease: is it time for mass screening? Best Pract Res Clin Gastroenterol 19(3):441–452. https://​doi.​org/​10.​1016/j.​bpg.​2005.​02.​004 16. Vriezinga SL, Auricchio R, Bravi E, Castillejo G, Chmielewska A, Crespo Escobar P et al (2014) Randomized feeding inter- vention in infants at high risk for celiac disease. N Engl J Med 371(14):1304–1315. https://​doi.​org/​10.​1056/​NEJMo​a1404​172 17. Bucci P, Carile F, Sangianantoni A, D'Angio F, Santarelli A, Lo Muzio L (2006) Oral aphthous ulcers and dental enamel defects in children with coeliac disease. Acta Paediatr 95(2):203–207. https://​doi.​org/​10.​1080/​08035​25050​03550​22 18. Organization WH (2013) Oral health surveys: basic methods. World Health Organization 19. Silness J, Loe H (1964) Periodontal disease in pregnancy. Ii. Cor- relation between oral hygiene and periodontal condition. Acta Odontol Scand 22:121–135. https://​doi.​org/​10.​3109/​00016​35640​ 89939​68 20. Aine L, Maki M, Collin P, Keyrilainen O (1990) Dental enamel defects in celiac disease. J Oral Pathol Med 19(6):241–245. https://​doi.​org/​10.​1111/j.​1600-​0714.​1990.​tb008​34.x 21. Lewis D, Haridy J, Newnham ED (2017) Testing for coeliac dis- ease. Aust Prescr 40(3):105–108. https://​doi.​org/​10.​18773/​austp​ rescr.​2017.​029 22. Gerenli N, Dursun F, Celtik C, Kirmizibekmez H (2021) Signifi- cant improvement in bone mineral density in pediatric celiac dis- ease: even at six months with gluten-free diet. J Pediatr Endocrinol Metab 34(3):341–348. https://​doi.​org/​10.​1515/​jpem-​2020-​0292 23. Taylor AK, Lebwohl B, Snyder CL, Green PHR (1993) Celiac disease. In: Adam MP, Mirzaa GM, Pagon RA, et  al, eds. GeneReviews((R)). 24. Shteyer E, Berson T, Lachmanovitz O, Hidas A, Wilschanski M, Menachem M et al (2013) Oral health status and salivary proper- ties in relation to gluten-free diet in children with celiac disease. J Pediatr Gastroenterol Nutr 57(1):49–52. https://​doi.​org/​10.​1097/​ MPG.​0b013​e3182​8b3705 25. See J, Murray JA (2006) Gluten-free diet: the medical and nutri- tion management of celiac disease. Nutr Clin Pract 21(1):1–15. https://​doi.​org/​10.​1177/​01154​26506​02100​101 26. Verma AK, Lionetti E, Gatti S, Franceschini E, Catassi GN, Catassi C (2019) Contribution of oral hygiene and cosmetics on contamination of gluten-free diet: do celiac customers need to worry about? J Pediatr Gastroenterol Nutr 68(1):26–29. https://​ doi.​org/​10.​1097/​MPG.​00000​00000​002129 27. Mahan LK, Raymond JL (2016) Krause’s food & the nutrition care process-e-book. Elsevier Health Sciences 28. Ogata BN, Hayes D (2014) Position of the Academy of Nutri- tion and Dietetics: nutrition guidance for healthy children ages 2 to 11 years. J Acad Nutr Diet 114(8):1257–1276. https://​doi.​ org/​10.​1016/j.​jand.​2014.​06.​001 29. Al-Toma A, Volta U, Auricchio R, Castillejo G, Sanders DS, Cellier C et al (2019) European Society for the Study of Coeliac Disease (ESsCD) guideline for coeliac disease and other gluten- related disorders. United European Gastroenterol J 7(5):583– 613. https://​doi.​org/​10.​1177/​20506​40619​844125 30. Tsami A, Petropoulou P, Panayiotou J, Mantzavinos Z, Roma- Giannikou E (2010) Oral hygiene and periodontal treatment needs in children and adolescents with coeliac disease in Greece. Eur J Paediatr Dent 11(3):122–126 31. Pedersen AML, Belstrøm D (2019) The role of natural sali- vary defences in maintaining a healthy oral microbiota. J Dent 80:3–12. https://​doi.​org/​10.​1016/j.​jdent.​2018.​08.​010 32. Dawes C, Pedersen AM, Villa A, Ekstrom J, Proctor GB, Vis- sink A et al (2015) The functions of human saliva: a review sponsored by the World Workshop on Oral Medicine VI. Arch Oral Biol 60(6):863–874. https://​doi.​org/​10.​1016/j.​archo​ralbio.​ 2015.​03.​004 33. Dane A, Gurbuz T (2016) Clinical evaluation of specific oral and salivary findings of coeliac disease in eastern Turkish paediatric patients. Eur J Paediatr Dent 17(1):53–56 34. Lahteenoja H, Toivanen A, Viander M, Maki M, Irjala K, Raiha I et al (1998) Oral mucosal changes in coeliac patients on a gluten- free diet. Eur J Oral Sci 106(5):899–906. https://​doi.​org/​10.​1046/j.​ 0909-​8836.​1998.​eos10​6501.x 35. de Carvalho FK, de Queiroz AM, Bezerra da Silva RA, Sawamura R, Bachmann L, Bezerra da Silva LA et al (2015) Oral aspects in celiac disease children: clinical and dental enamel chemical evalu- ation. Oral Surg Oral Med Oral Pathol Oral Radiol 119(6):636– 643. https://​doi.​org/​10.​1016/j.​oooo.​2015.​02.​483 36. Acar S, Yetkiner AA, Ersin N, Oncag O, Aydogdu S, Arikan C (2012) Oral findings and salivary parameters in children with celiac disease: a preliminary study. Med Princ Pract 21(2):129– 133. https://​doi.​org/​10.​1159/​00033​1794 37. Rashid M, Zarkadas M, Anca A, Limeback H (2011) Oral mani- festations of celiac disease: a clinical guide for dentists. J Can Dent Assoc 77:b39 38. Perez-Davidi M (2011) The relationship between celiac disease (CD) and dental problems. Refuat Hapeh Vehashinayim (1993) 28(4):12–18 37 39. Souto-Souza D, da Consolacao Soares ME, Rezende VS, de Lacerda Dantas PC, Galvao EL, Falci SGM (2018) Association between developmental defects of enamel and celiac disease: a meta-analysis. Arch Oral Biol 87:180–190. https://​doi.​org/​10.​ 1016/j.​archo​ralbio.​2017.​12.​025 40. Comino I, Sousa C (2022) Advances in celiac disease and gluten- free diet. Nutrients 14(3). https://​doi.​org/​10.​3390/​nu140​30570 41. Priovolou CH, Vanderas AP, Papagiannoulis L (2004) A compara- tive study on the prevalence of enamel defects and dental caries in children and adolescents with and without coeliac disease. Eur J Paediatr Dent 5(2):102–106 42. Mina SS, Azcurra AI, Dorronsoro S, Brunotto MN (2008) Altera- tions of the oral ecosystem in children with celiac disease. Acta Odontol Latinoam 21(2):121–126 43. Wierink CD, van Diermen DE, Aartman IH, Heymans HS (2007) Dental enamel defects in children with coeliac disease. Int J Pae- diatr Dent 17(3):163–168. https://​doi.​org/​10.​1111/j.​1365-​263X.​ 2006.​00816.x 44. Campisi G, Di Liberto C, Iacono G, Compilato D, Di Prima L, Calvino F et al (2007) Oral pathology in untreated coeliac [cor- rected] disease. Aliment Pharmacol Ther 26(11-12):1529–1536. https://​doi.​org/​10.​1111/j.​1365-​2036.​2007.​03535.x 45. Nikiforuk G, Fraser D (1981) The etiology of enamel hypoplasia: a unifying concept. J Pediatr 98(6):888–893. https://​doi.​org/​10.​ 1016/​s0022-​3476(81)​80580-x https://doi.org/10.1186/s12903-021-01976-4 https://doi.org/10.1038/s41575-021-00511-8 https://doi.org/10.1038/s41575-021-00511-8 https://doi.org/10.3390/dj6010001 https://doi.org/10.3390/dj6010001 https://doi.org/10.1016/j.bpg.2005.02.004 https://doi.org/10.1056/NEJMoa1404172 https://doi.org/10.1080/08035250500355022 https://doi.org/10.3109/00016356408993968 https://doi.org/10.3109/00016356408993968 https://doi.org/10.1111/j.1600-0714.1990.tb00834.x https://doi.org/10.18773/austprescr.2017.029 https://doi.org/10.18773/austprescr.2017.029 https://doi.org/10.1515/jpem-2020-0292 https://doi.org/10.1097/MPG.0b013e31828b3705 https://doi.org/10.1097/MPG.0b013e31828b3705 https://doi.org/10.1177/011542650602100101 https://doi.org/10.1097/MPG.0000000000002129 https://doi.org/10.1097/MPG.0000000000002129 https://doi.org/10.1016/j.jand.2014.06.001 https://doi.org/10.1016/j.jand.2014.06.001 https://doi.org/10.1177/2050640619844125 https://doi.org/10.1016/j.jdent.2018.08.010 https://doi.org/10.1016/j.archoralbio.2015.03.004 https://doi.org/10.1016/j.archoralbio.2015.03.004 https://doi.org/10.1046/j.0909-8836.1998.eos106501.x https://doi.org/10.1046/j.0909-8836.1998.eos106501.x https://doi.org/10.1016/j.oooo.2015.02.483 https://doi.org/10.1159/000331794 https://doi.org/10.1016/j.archoralbio.2017.12.025 https://doi.org/10.1016/j.archoralbio.2017.12.025 https://doi.org/10.3390/nu14030570 https://doi.org/10.1111/j.1365-263X.2006.00816.x https://doi.org/10.1111/j.1365-263X.2006.00816.x https://doi.org/10.1111/j.1365-2036.2007.03535.x https://doi.org/10.1016/s0022-3476(81)80580-x https://doi.org/10.1016/s0022-3476(81)80580-x 3588 Clinical Oral Investigations (2023) 27:3579–3588 1 3 46. Munoz F, Del Rio N, Sonora C, Tiscornia I, Marco A, Hernandez A (2012) Enamel defects associated with coeliac disease: puta- tive role of antibodies against gliadin in pathogenesis. Eur J Oral Sci 120(2):104–112. https://​doi.​org/​10.​1111/j.​1600-​0722.​2012.​ 00949.x 47. Mariani P, Mazzilli MC, Margutti G, Lionetti P, Triglione P, Petronzelli F et al (1994) Coeliac disease, enamel defects and HLA typing. Acta Paediatr 83(12):1272–1275. https://​doi.​org/​10.​ 1111/j.​1651-​2227.​1994.​tb130​14.x 48. Ortega Paez E, Junco Lafuente P, Baca Garcia P, Maldonado Lozano J, Llodra Calvo JC (2008) Prevalence of dental enamel defects in celiac patients with deciduous dentition: a pilot study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 106(1):74–78. https://​doi.​org/​10.​1016/j.​tripl​eo.​2008.​01.​022 49. Cheng J, Malahias T, Brar P, Minaya MT, Green PH (2010) The association between celiac disease, dental enamel defects, and aphthous ulcers in a United States cohort. J Clin Gastroenterol 44(3):191–194. https://​doi.​org/​10.​1097/​MCG.​0b013​e3181​ac9942 50. Farmakis E, Puntis JW, Toumba KJ (2005) Enamel defects in children with coeliac disease. Eur J Paediatr Dent 6(3):129–132 51. Campisi G, Di Liberto C, Carroccio A, Compilato D, Iacono G, Procaccini M et al (2008) Coeliac disease: oral ulcer prevalence, assessment of risk and association with gluten-free diet in chil- dren. Dig Liver Dis 40(2):104–107. https://​doi.​org/​10.​1016/j.​dld.​ 2007.​10.​009 52. Aydemir S, Tekin NS, Aktunc E, Numanoglu G, Ustundag Y (2004) Celiac disease in patients having recurrent aphthous sto- matitis. Turk J Gastroenterol 15(3):192–195 53. Shakeri R, Zamani F, Sotoudehmanesh R, Amiri A, Mohamadne- jad M, Davatchi F et al (2009) Gluten sensitivity enteropathy in patients with recurrent aphthous stomatitis. BMC Gastroenterol 9:44. https://​doi.​org/​10.​1186/​1471-​230X-9-​44 Publisher’s note  Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law. https://doi.org/10.1111/j.1600-0722.2012.00949.x https://doi.org/10.1111/j.1600-0722.2012.00949.x https://doi.org/10.1111/j.1651-2227.1994.tb13014.x https://doi.org/10.1111/j.1651-2227.1994.tb13014.x https://doi.org/10.1016/j.tripleo.2008.01.022 https://doi.org/10.1097/MCG.0b013e3181ac9942 https://doi.org/10.1016/j.dld.2007.10.009 https://doi.org/10.1016/j.dld.2007.10.009 https://doi.org/10.1186/1471-230X-9-44 Nutrition and oral health in children with recently and previously diagnosed celiac disease Abstract Objectives Materials and methods Results Conclusions Clinical relevance Introduction Methods Oral examination Salivary parameters Statistical analysis Results Discussion Availability of data and materials References