Gluten sensitivity enteropathy in patients with recurrent aphthous stomatitis

Abstract

BackgroundGluten sensitive enteropathy (GSE) is an autoimmune enteropathy triggered by the ingestion of gluten-containing grains in susceptible individuals. Recurrent aphthous stomatitis (RAS) may be the sole manifestation of GSE. The aim of this study was to determine the prevalence of gluten sensitivity enteropathy (GSE) in a large group of patients with RAS and assess the efficacy of gluten free diet (GFD) on the improvement of aphthous lesions in those who were diagnosed with GSE.MethodsTwo hundred and forty seven patients with RAS were included. The patients had at least three aphthous attacks per year. Patients were screened by IgA anti-endomysial antibody (EMA), IgA anti tissue transglutaminase (TTG) and serum IgA level. Those with a positive serology underwent endoscopic biopsies of the duodenal mucosa and patients with negative serology were excluded. The diagnosis of GSE was based on a positive serological test and abnormal duodenal histology. For patients with GSE, gluten free diet was recommended.ResultsSix out of 247 RAS patients had positive TTG test alone, and one had positive EMA and TTG. All 7 patients with positive serologic tests underwent duodenal biopsies. Histological findings were compatible with GSE in all of them (Marsh I in four patients, Marsh II in two patients and Marsh IIIB in one another.). The mean age of GSE patients was 27.42 ± 10.56 (range, 13 to 40) years old. They were suffering from RAS for an average duration of 4.5 years. All of the 7 GSE patients had not responded to the routine anti-aphthae medications, including topical corticosteroids, tetracycline and colchicine. Four patients who adhered to a strict gluten-free diet showed noticeable improvement in their aphthous lesions over a period of 6 months.ConclusionA significant minority (e.g. 2.83%) of RAS patients have GSE. This could be compared with the 0.9% prevalence of GSE in the general population of Iran. This study suggests that evaluation for celiac disease is appropriate in patients with RAS. Additionally, the unresponsiveness to conventional anti-aphthae treatment could be an additional risk indicator.

Oral Findings and Salivary Parameters in Children with Celiac Disease: A Preliminary Study

“…It was reported that CD patients with RAS showed a significant improvement in their aphthous lesions after GFD [8,17,27]. On the other hand, Hunter et al [28] examined the effects of GFD in patients with RAS and without CD and found no statistical significance between the study group with GFD and the control groups.…”

“…Genetic, immunological and microbial factors may play a role in the occurrence of RAS. Also local trauma, stress, food intake, some drugs, hormonal changes or vitamin and trace element deficiencies could play a role [27]. However, some studies reported nonsignificant differences in RAS in CD patients versus controls [8,16].…”

Risk of morbidity in contemporary celiac disease

“…Recurrent aphthous ulcers occur more commonly in patients with celiac disease in some series [162,164] but not all [166]. The frequency of celiac disease in those with recurrent ulcers may be higher that in the general population with a threefold increase, but small bowel histological changes may be mild [167]. When ulcers are present, a gluten-free diet is an effective cure [168].…”

Treatments for Recurrent Aphthous Stomatitis

“…The researchers concluded that patients who were unresponsive to RAS treatments should always be investigated for gluten intolerance. 7 Furthermore, there are many cases of subclinical celiac disease in patients whose RAS is reduced when a glutenfree diet is adopted. In addition, both confirmed and subclinical/silent celiac disease are increasing in incidence.…”