**11. Dental defects in CD**

Oral manifestations are overlooked in CD patients; the long list of clinical signs and symptoms associated with CD includes dental enamel hypoplasia, aphthous

ulcers and delayed eruption of teeth [77]. The dental enamel defects are more common in deciduous dentition. It can involve all four quadrants, but more commonly involved maxillary and mandibular incisors and molars [78]. The exact cause is not understood but it may be due to increased level of HLA DR3 in their blood. This antigen has an association with celiac disease. Dental enamel hypoplasia, a nutritionally related defect of the enamel, presented as pits, lines or grooves on the teeth. Its prevalence ranges from 10 to 97%, and appears to more common in children with CD, as compared to adults [79]. Its prevalence in CD, is much higher than general population, and it is contributed both to nutritional and immunological factors. Another enamel defect, either partial or complete, can sometimes be the only symptoms in children with CD. It is thus advisable to screen children with enamel defects for CD. The other oral manifestation aphthous ulcer or canker sores are also seen in CD, though not specific for CD. Aphthous ulcers, though regresses on gluten free diet [80].

Delayed tooth eruption, another manifestation of CD, has been reported in 27% of patients with CD. The possible cause is probably malnutrition. A high prevalence of enamel hypoplasia is around 66% in CD patients. Formation of plaque is less frequent in patients who are on gluten free diet, probably because of multiple meals in between and use of fluoride toothpaste.

There are other oral problem related to celiac disease, which include recurrent aphthous stomatitis, atrophic glossitis, dry mouth syndrome and squamous cell carcinoma of the oropharynx.
