Oral Mucosal Lesions, Chronic (Mouth Soreness)

What Are Chronic Oral Mucosal Lesions?

Chronic lesions of the oral mucosa are disorders of the mouth that are characterized by soreness and sores of the soft mucosal lining of the mouth.

What Are Chronic Oral Mucosal Lesions In Celiac Disease and/or Gluten Sensitivity?

• Relationship between chronic lesions of the oral mucosa and celiac disease. Chronic lesions of the oral mucosa are an associated disorder and are symptoms of malabsorption and/or an oral immune reaction to gluten exposure characterized by painful inflammation and/ or lesions (sores).
• Relationship between chronic lesions of the oral mucosa and gluten. Moderate to severe lymphocytic inflammation of the oral mucosa tends to increase with a longer duration of celiac disease with or without treatment. However, lack of strict compliance with a gluten free diet may be related to high prevalence of oral changes and symptoms since raised serum endomysium IgA antibody titres were found in study patients. Even minute amounts of gluten may lead to oral manifestations since ingested food first contacts the oral surfaces. Changes are not associated with mechanical irritation or smoking.¹
• Relationship between chronic lesions of the oral mucosa and diagnosis. Lesions carry profound diagnostic importance in celiac disease and may be the only presenting features.²
• Relationship between chronic lesions of the oral mucosa and dentist. Specific oral manifestations are effective risk indicators of celiac disease and for this reason an early diagnosis with a consequent better prognosis can be performed by the dentist.³
• Relationship between chronic lesions of the oral mucosa and intestinal lesions. A study investigating the pattern of T-cell subsets in the oral mucosa of young adults with celiac disease to determine if the oral mucosa could reflect the histopathological inflammatory alterations of the intestine confirms the oral cavity to be a site of involvement of celiac disease and its possible diagnostic potentiality in this disease.⁴

How Prevalent Are Chronic Oral Mucosal Lesions In Celiac Disease and/or Gluten Sensitivity?

Chronic lesions of the oral mucosa are common in untreated celiac disease and 55.5% of treated patients not following a strict gluten free Diet.⁵

In a study of children, a prevalence of oral soft tissue lesions was 62% in diagnosed celiac patients, 76.2% in potential celiac patients, and 12.96% in controls.³

What Are The Symptoms Of Chronic Oral Mucosal Lesions?

Chronic lesions of the oral mucosa are marked by these symptoms:

• Oral soreness.
• Burning sensations.
• Xerostoma (dryness).
• The tongue is most often affected.⁶
• Canker sores affect the inside mucosal lining of the mouth.

How Do Oral Mucosal Lesions Develop In Celiac Disease and/or Gluten Sensitivity?

• Chronic lesions of the oral mucosa result from micronutrient deficiencies induced by celiac disease and are celiac disease-related.¹
• Deficiencies include any of these: vitamin B12, vitamin C, vitamin K, thiamin, riboflavin, niacin, pyridoxine, iron, omega 3-fatty acids, and zinc.
• Note: As long as nutritional deficiencies persist, individuals with celiac disease are at risk for developing oral soreness.

Do Oral Mucosal Lesions Respond To Gluten-Free Diet?

Celiac disease-related oral mucosal lesions respond to a strict only gluten free diet, but often persist.¹

Integrity of the oral mucosa depends on adequate nutrient levels to maintain health and so prevent oral soreness.

6 Steps To Improve Oral Soreness In Celiac Disease and/or Gluten Sensitivity:

• [dropcap]1[/dropcap]Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:

[box type=”shadow” ]Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both mouth and gut health.

• Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
• A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
• Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

• Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
• Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

• Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
• Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.⁷
• The intestinal lining may take up to a year to heal.[/box]

• [dropcap]2[/dropcap] Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

[box type=”shadow” ]Here Are Major Inflammatory Food Types That Reduce Healing:

• Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.⁸
• Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
• Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.⁸
• Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.⁸.
• Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.⁸
• Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
• Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.⁸
• Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.⁸[/box]

[box type=”shadow” ]Here Are Important Anti-Inflammatory Food Types to Promote Health:

• Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
• Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes lettuce, kale, onion, broccoli, garlic, and others.
• High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
• Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
• Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
• Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
• Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
• Protective Herbs and Spices.  See below #6 below for examples.[/box]

• [dropcap]3[/dropcap] Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

 

• [dropcap]4[/dropcap] Manage Your Medications Safely:

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Certain prescription drugs deplete one or more of these nutrients that can cause oral mucosal lesions: vitamin B12, vitamin C, vitamin K, thiamin (vitamin B1), riboflavin (vitamin B2), niacin (vitamin B3), pyridoxine (vitamin B6), iron, omega 3-fatty acids, and zinc. Ask your doctor or pharmacist about this possible adverse effect if you are taking any of the drugs listed below. Do not stop prescribed medications without supervision.

This is not a complete listing.

ANTACIDS / ULCER MEDICATIONS

• Pepcid®, Tagamet®, Zantac® deplete Iron, Vitamin B12, Zinc.
• Magnesium and Aluminum Antacid preparations (Gaviscon®, Maalox®, Mylanta®) deplete Iron, Vitamin B12, Zinc.
• Prevacid®, Prilosec® deplete Vitamin B12.

ANTI-DEPRESSANTS

• Adapin®, Aventyl®, Elavil®, Pamelor®, and others deplete Vitamin B12, Riboflavin.

ANTIBIOTICS disrupt intestinal permeability.

• Gentomycin, Neomycin, Streptomycin, Cephalosporins, Penicillins deplete B Vitamins, Vitamin K, Vitamin C.
•  Tetracyclines deplete Iron, Vitamin B6, Zinc, Riboflavin.
• Cipro depletes Zinc.

ANTI-INFLAMMATORIES disrupt intestinal permeability.

• Corticosteroids (Prednisone, Medrol®, Aristocort®, Decadron) deplete  Zinc, Vitamin C, Vitamin B6, Vitamin B12.
• Aspirin and Salicylates deplete Vitamin C, Iron.

ANTICONVULSANTS

• Phenobarbital and Barbituates; and Dilantin®, Tegretol®, Mysoline®, Depakane/Depacon® deplete Vitamin B12, Vitamin B1, Vitamin K, Zinc.

ANTIVIRAL AGENTS

• Zidovudine (Retrovir®, AZT and other related drugs) deplete Zinc, Vitamin B12.

CARDIOVASCULAR DRUGS

• Antihypertensives (Catapres®, Aldomet) deplete Vitamin B6, Vitamin B1, Zinc.
• ACE Inhibitors (Capotenv, Vasotec®, Monopril® and others) deplete Zinc.

CHOLESTEROL DRUGS

• Colestid® and Questran® deplete Vitamin A, Vitamin B12, Vitamin K, Iron.

DIABETIC DRUGS 

• Metformin® depletes Vitamin B12.

DIURETICS

• Thiazide Diuretics (Hydrochlorothiazide, Enduron®, Diuril®, Lozol®, Zaroxolyn®, Hygroton® and others) deplete Zinc.
• Loop Diuretics (Lasix®, Bumex®, Edecrin®) depletes Vitamin B1, Vitamin B6, Vitamin C, Zinc.
• Potassium Sparing Diuretics (Midamor®, Aldactone®, Dyrenium® and others) deplete Zinc.

FEMALE HORMONES disrupt intestinal permeability.

• Oral Contraceptives (Norinyl®, Ortho-Novum®, Triphasil®, and others) deplete Vitamin B2, Vitamin B3, Vitamin B6, Vitamin B12, Vitamin C, Zinc.
• Oral Estrogen/Hormone Replacement (Evista®, Prempro®, Premarin®, Estratab® and others) deplete Vitamin B2, Vitamin B6, Vitamin B12, Vitamin C, Zinc.

MAJOR TRANQUILIZERS  

• Thorazine®, Mellaril®, Prolixin®, Serentil® and others deplete Coenzyme Q10, Vitamin B12.

WEIGHT LOSS DRUGS THAT BIND FAT also interfere with absorption of some nutrients.

• Zenicol (Orlistat®) depletes Vitamin K.

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• [dropcap]5[/dropcap]Nutritional Supplements To Help Correct Deficiencies:

[box type=”shadow” ]

The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.

• Multivitamin/mineral combination once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications. Contains thiamin, riboflavin and pyridoxine.
• Vitamin B12  as prescribed following blood test for status.
• Vitamin A as prescribed following blood test for status.
• Chelated magnesium  as prescribed but do not take at same time as calcium because they compete for absorption.
• Chelated zinc as prescribed but do not take at same time as calcium or other minerala because they compete for absorption.

Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.[/box]

• [dropcap]6[/dropcap]Manage Natural Remedies: 

[box type=”shadow” ]Hydration:

• Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
• If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
• Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
• What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.[/box]

[box type=”shadow” ]Carminatives. The following  anti-inflammatory plant sources called carminitives help heal the digestive tract. They also tone the digestive muscles which improves peristalsis, thus aiding in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort.

Carminative Food Remedies:

• Raspberry.
• Carrot is also a cleansing digestive tonic.
• Grape is also bile stimulating and a cleansing remedy for sluggish digestion and laxative.
• Redbeets also stimulate and improve digestion and are easily digested.
• Cabbage also stimulates and improves digestion and is also a liver decongestant.
• Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
• Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.

Carminative Herb Remedies:

• Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa.  Drink as tea or use in cooking.
• Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
• Parsley also relieves indigestion.
• Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion.
• Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.

Carminative Spice Remedies:

• Cloves are also antispasmodic.
• Nutmeg is also useful for indigestion.
• Ginger.[/box]

[box type=”shadow” ]Exercise Helps:

Exercise improves circulation and rids the body of toxins.

• Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
• Weight training builds muscle. Read more about Exercise and Fitness.
• Stretching improves flexibilty. Read more about Exercise and Fitness.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal. [/box]

What Do Medical Research Studies Tell About Are Oral Mucosal Lesions In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Histopathological findings in the oral mucosa of celiac patients. “ This study investigating the pattern of T-cell subsets in the oral mucosa of young adults with celiac disease to determine if the oral mucosa could reflect the histopathological inflammatory alterations of the intestine confirms the oral cavity to be a site of involvement of celiac disease and its possible diagnostic potentiality in this disease.

A group of 37 patients (age range 20-38 years; female: male ratio 28:9) with CD were enrolled. Out of 37 patients, 19 patients (group A) followed a gluten free diet (GFD) -2 patients from less than one year; 6 patients between 1 and 5 years; 11 patients more than 5 years- while 18 patients (group B) were still untreated. Fifteen healthy volunteers (age range 18-35 years, female: Male ratio 11:4) served as controls for the CD patients.Biopsy specimens were taken from normal looking oral mucosa. The immunohistochemical investigation was performed with monoclonal antibodies to CD3, CD4, CD8, and gamma/delta-chains T cell receptor (TCR).

The T-lymphocytic inflammatory infiltrate was significantly (p < 0.0001) increased in group B (both compared with group A and with the control group).⁴

“Clinical Evaluation of Specific Oral Manifestations in Pediatric Patients with Ascertained versus Potential Celiac Disease: A Cross-Sectional Study.” This study investigating the oral hard and soft tissue lesions in potential and ascertained celiac children in comparison with healthy controls found that the overall oral lesions were more frequently present in celiac disease patients than in controls.

50 ascertained children, 21 potential celiac patients, and 54 controls were recruited and the oral examination was performed. The prevalence of oral soft tissue lesions was 62% in ascertained celiac, 76.2% in potential celiac patients, and 12.96% in controls,³

“Oral mucosal changes in coeliac patients on a gluten-free diet.” This study investigating 128 celiac disease patients on gluten free diet demonstrated intraepithelial T-cells and mast cells were found significantly more frequent in treated celiac disease patients than in controls. Moderate to severe lymphocytic inflammation of the oral mucosa tends to increase with a longer duration of celiac disease with or without treatment. However, lack of strict compliance with a gluten free diet may be related to high prevalence of oral changes and symptoms since raised serum endomysium IgA antibody titres were found in study patients. Even minute amounts of gluten may lead to oral manifestations since ingested food first contacts the oral surfaces. Changes are not associated with mechanical irritation or smoking.²

Sources:

1. Lahteenoja H, Toivanen A, Viander M, Maki M, Irjala K, Raiha I, Syrjanen S. Oral mucosal changes in coeliac patients on a gluten-free diet. European Journal of Oral Sciences. Oct 1998;106(5):899,8p. [↩] [↩] [↩]
2. Lahteenoja H, Toivanen A, Viander M, Maki M, Irjala K, Raiha I, Syrjanen S. Oral mucosal changes in coeliac patients on a gluten-free diet. European Journal of Oral Sciences. Oct 1998;106(5):899,8p. [↩] [↩]
3. Bramanti E, Cicciù M, Matacena G, Costa S, Magazzù G. Clinical Evaluation of Specific Oral Manifestations in Pediatric Patients with Ascertained versus Potential Coeliac Disease: A Cross-Sectional Study. Gastroenterol Res Pract. 2014;2014:934159. doi: 10.1155/2014/934159. [↩] [↩] [↩]
4. Bardellini E, Amadori F, Ravelli A, Salemme M, Lonardi S, Villanacci V, Majorana A. Histopathological findings in the oral mucosa of celiac patients. Rev Esp Enferm Dig. 2014 Feb;106(2):86-91. [↩] [↩]
5. Lahteenoja H, Toivanen A, Viander M, Maki M, Irjala K, Raiha I, Syrjanen S. Oral mucosal changes in coeliac patients on a gluten-free diet. European Journal of Oral Sciences. Oct 1998;106(5):899,8p. [↩]
6. Lahteenoja H, Toivanen A, Viander M, Maki M, Irjala K, Raiha I, Syrjanen S. Oral mucosal changes in coeliac patients on a gluten-free diet. European Journal of Oral Sciences. Oct 1998;106(5):899,8p. [↩]
7. Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
8. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩] [↩]