Frightening facts about milk


A large observational cohort study[1]in Sweden found that women consuming more than 3 glasses of milk a day had almost twice the mortality over 20 years compared to those women consuming less than one glass a day. In addition, the high milk-drinkers did not have improved bone health. In fact, they had more fractures, particularly hip fractures.

Interestingly, the study also found that fermented milk products (cheese and yogurt) significantly decreased mortality and fractures among these women. For each serving of these fermented dairy products, the rate of mortality and hip fractures was reduced by 10-15%. The researchers pin the negative effects of liquid milk on D-galactose, a breakdown product of lactose that has been shown to be pro-inflammatory. Milk has much more D-galactose than does cheese or yogurt.

I am surprised that this study garnered so much mass media attention upon its release, as it highlights the deleterious side of milk, but I also think it is important to keep the findings in context. And when it comes to the health effects of dairy, the context is not so pretty:

In observational studies both across countries and within single populations, higher dairy intake has been linked to increased risk of prostate cancer (cited in [2]).Observational cohort studies have shown higher diary intake is linked to higher ovarian cancer risk (cited in [2]).Cow’s milk protein may play a role in triggering type 1 diabetes through a process called molecular mimicry[3].Across countries, populations that consume more dairy have higher rates of multiple sclerosis[4].In interventional animal experiments and human studies, dairy protein has been shown to increase IGF-1 (Insulin-like Growth Factor-1) levels. Increased levels of IGF-1 has now been implicated in several cancers[5].In interventional animal experiments[6] and human experiments[7], dairy protein has been shown to promote increased cholesterol levels (in the human studies and animal studies) and atherosclerosis (in the animal studies).The primary milk protein (casein) promotes cancer initiated by a carcinogen in experimental animal studies[8].D-galactose has been found to be pro-inflammatory and actually is given to create animal models of aging[1].Higher milk intake is linked to acne[9].Milk intake has been implicated in constipation[10] and ear infections (cited in [2]).Milk is perhaps the most common self-reported food allergen in the world[11].Much of the world’s population cannot adequately digest milk due to lactose intolerance.

So despite being very pleased that the public is glimpsing some of the evidence against milk in this recent study (though they also could be hearing about the benefits of cheese and yogurt from this same study), I think there is a far more powerful story; a story that takes into account the largely hidden context of diet and dairy research. There is a wealth of indirect evidence of very serious possible harms of consuming dairy foods, and, on the flip side, the evidence that milk prevents fractures is scant.

As we look beyond the headlines, it is hard to think that we should continue to consume the lactation fluid that exists in nature to nourish and rapidly grow calves.


Michaelsson K, Wolk A, Langenskiold S, et al. Milk intake and risk of mortality and fractures in women and men: cohort studies. Bmj 2014;349:g6015. Lanou AJ. Should dairy be recommended as part of a healthy vegetarian diet? Counterpoint. The American journal of clinical nutrition 2009;89:1638S-42S. Dahl-Jorgensen K, Joner G, Hanssen KF. Relationship between cows’ milk consumption and incidence of IDDM in childhood. Diabetes Care 1991;14:1081-3. Malosse D, Perron H, Sasco A, Seigneurin JM. Correlation between milk and dairy product consumption and multiple sclerosis prevalence: a worldwide study. Neuroepidemiology 1992;11:304-12. Key TJ. Diet, insulin-like growth factor-1 and cancer risk. Proc Nutr Soc 2011:1-4. Kritchevsky D. Dietary protein, cholesterol and atherosclerosis: a review of the early history. The Journal of nutrition 1995;125:589S-93S. Gardner CD, Messina M, Kiazand A, Morris JL, Franke AA. Effect of two types of soy milk and dairy milk on plasma lipids in hypercholesterolemic adults: a randomized trial. Journal of the American College of Nutrition 2007;26:669-77. Youngman LD, Campbell TC. Inhibition of aflatoxin B1-induced gamma-glutamyltranspeptidase positive (GGT+) hepatic preneoplastic foci and tumors by low protein diets: evidence that altered GGT+ foci indicate neoplastic potential. Carcinogenesis 1992;13:1607-13. Spencer EH, Ferdowsian HR, Barnard ND. Diet and acne: a review of the evidence. Int J Dermatol 2009;48:339-47. Caffarelli C, Baldi F, Bendandi B, Calzone L, Marani M, Pasquinelli P. Cow’s milk protein allergy in children: a practical guide. Italian journal of pediatrics 2010;36:5. Rona RJ, Keil T, Summers C, et al. The prevalence of food allergy: a meta-analysis. J Allergy Clin Immunol 2007;120:638-46.


The power of essential oils

It’s not the alcohol in listerine that kills germs, the alcohol binds the essential oil in solution. I recommend this for all my patients that can tolerate it, great germ killing and I use it myself twice a day! (no I do not get paid by listerine, I just think it’s a great product with solid studies that demonstrate it’s efficacy)


LISTERINE® Fights Germs with Essential Oils

The power of LISTERINE® Antiseptic comes from a formula of four essential oils that kill millions of germs on contact. Our fixed combination of eucalyptol, menthol, methyl salicylate, and thymol continues to deliver unsurpassed results. No other branded mouthwash has this formula. And that’s why no other mouthwash feels or works like LISTERINE®.

LISTERINE® Penetrates Plaque Biofilm and Kills Germs

Biofilm is a more recent term for the bacterial film on your teeth we call plaque. Biofilm is an organized community of germs in a gooey matrix that enables them to multiply and survive inside your mouth. Brushing and flossing help disrupt and remove this biofilm, but sometimes may miss hard to reach areas—prime real estate for gingivitis causing germs. LISTERINE® Antiseptic rapidly penetrates the biofilm to kill plaque and gingivitis germs.

Baked Pear Crisp

Today’s recipe is brought to you from the Engine 2 Diet

  • 6 pears, peeled and cored, divided
  • 2 teaspoons finely grated lemon zest
  • 1/2 cup raisins, soaked in warm water for about an hour
  • 1 1/2 tablespoon lemon juice
  • 1 teaspoon pure vanilla extract (optional)
  • 3 pitted dates, soaked in warm water for about an hour
  • 2 cups Engine 2 Plant-Strong™ Rip’s Big Bowl cereal
  • 1/2 teaspoon ground cinnamon
  • 1/4 teaspoon fine sea salt

Preheat the oven to 375°F. Thinly slice 5 of the pears and place in a large bowl. Add lemon zest and toss. Chop remaining pear and place in a blender. Drain raisins, reserving the soaking liquid. Add raisins to the blender along with lemon juice and vanilla. Blend until smooth, adding a few tablespoons of the reserved soaking liquid as needed to make a purée. Pour the mixture over pears and toss gently until coated. Scrape the mixture into an 8 x 8-inch glass baking dish or small casserole dish and smooth the top.

Drain dates and place them in a food processor. Add cereal, cinnamon and salt; pulse until the mixture is finely chopped and starts to form loose clumps. Spread the mixture evenly over pears. Bake until topping is browned and crisp and filling is bubbling, 25 to 30 minutes. Serve warm or at room temperature.

Nutritional Info:
Per Serving:320 calories (40 from fat), 4.5g total fat, 0g saturated fat, 0mg cholesterol,135mg sodium, 72g carbohydrate (11g dietary fiber, 29g sugar), 6g protein

Ancient Romans had less Gum Disease? had less gum disease than modern Britons

The Roman-British population from c. 200-400 AD appears to have had far less gum disease than we have today, according to a study of skulls at the Natural History Museum led by a King’s College London periodontist. The surprise findings provide further evidence that modern habits like smoking can be damaging to oral health.


Gum disease, also known as periodontitis, is the result of a chronic inflammatory response to the build-up of dental plaque. Whilst much of the population lives with mild gum disease, factors such as tobacco smoking or medical conditions like diabetes can trigger more severe chronic periodontitis, which can lead to the loss of teeth.

The study, published in the British Dental Journal, examined 303 skulls from a Romano-British burial ground in Poundbury, Dorset for evidence of dental disease.  Only 5% of the skulls showed signs of moderate to severe gum disease, compared to today’s population of which around 15-30% of adults have chronic progressive periodontitis.

However many of the Roman skulls, which form part of the collections in the Palaeontology department of the Natural History Museum,  showed signs of infections and abscesses, and half had caries (tooth decay). The Poundbury population also showed extensive tooth wear from a young age, as would be expected from a diet rich in coarse grains and cereals at the time.

The Poundbury cemetery community, genetically similar to modern European populations, was made up of countryside dwellers as well as a Romanised urban population. This was a non-smoking population and likely to have had very low levels of diabetes mellitus, two factors that are known to greatly increase the risk of gum disease in modern populations. Among the people who survived infancy, childhood illnesses and malnutrition into adulthood, the peak age at death appears to have been in their 40s. Infectious diseases are thought to have been a common cause of death at that time.

Professor Francis Hughes from the Dental Institute at King’s College London and lead author of the study said: “We were very struck by the finding that severe gum disease appeared to be much less common in the Roman British population than in modern humans, despite the fact that they did not use toothbrushes or visit dentists as we do today. Gum disease has been found in our ancestors, including in mummified remains in Egypt, and was alluded to in writings by the Babylonians, Assyrians and Sumerians as well as the early Chinese.”

Theya Molleson, co-author of the study from the Natural History Museum said: “This study shows a major deterioration in oral health between Roman times and modern England. By underlining the probable role of smoking, especially in determining the susceptibility to progressive periodontitis in modern populations, there is a real sign that the disease can be avoided. As smoking declines in the population we should see a decline in the prevalence of the disease.”

Notes to editors

For more information, please contact Charlotte Pool on  0207 848 3086,

‘The prevalence of Periodontal Disease in a Romano-British population c.200-400 AD’ by Tuija Raitapuro-Murray, Theya Molleson, and Francis Hughes is published in the British Dental Journal on Friday 24 October 2014.

Exploring Quinoa and My Family’s Favorite Quinoa Recipe

Quinoa originated in the Andes Mountains of South America, it is a seed of the goosefoot plant and is also called a “supergrain” although technically not a grain.   It is high in protein, and its protein is complete meaning it contains all the amino acids in the balanced amounts that our bodies require.

Quinoa is gluten free (for those that care) and the United Nations has indicated that the amino acid profile of quinoa is superior to that of most other grains and similar to that of casein, the complete protein in cow’s milk.

Unless labeled as prewashed, it should always be rinsed to remove the saponin covering the quinoa which is very bitter.

A favorite recipe in my house is a moroccan inspired Quinoa, Chickpea & Kale dish


2 TBSP Olive Oil, 1 Onion finely chopped, 1 carrot peeled and cut into small bite sized pieces, 5 cloves garlic finely minced, 1/4 tsp ground coriander, 1/2 cup quinoa rinsed, 1 1/2 cups vegetable or chicken broth, 1 cup canned chickpeas rinsed well, 2 Tbsp raisins (golden work well), 1 small bunch kale (2-3 leaves or 6 oz) stemmed and chopped into 1 inch pieces, optional 2 TBSP toasted pine nuts, 1 tsp lemon zest, 1 tsp lemon juice, pinch of salt, pinch of pepper

1. Heat 1 TBSP of the olive oil in a saucepan over medium-high heat, when oil is hot add onions and carrots until the onion is softened, about 5 minutes, then stir in the garlic, coriander and cook for another minute or so, then add the quinoa stirring like crazy until it is toasted

2. Add the broth, chickpeas, raisins, salt, and place kale on top and bring to a simmer.  Reduce the heat to low-medium at this point and cover and simmer until the quinoa is transparent and tender (about 20 min).  Off the heat stir in the remaining oil, pine nuts (optional), zest and juice from the lemon


Essential Oils

Is there something to essential oils?

My hygienist Kirsten was telling me about Young Living oils that she has been using and distributes as a way for her family to promote health.  This got me interested because I know that essential oils are the active ingredient in Listerine which have great anti-microbial properties.  Also recently during a flood at my house, the water mitigator said he would use essential oils of Thyme to prevent mold growth as it was natural and non-toxic which really appeals to me because of my 1 year old daughter.

I’m going to do some research on this, anybody have any experience or thoughts? Essential oils can be aerosolized through diffusers, applied topically, or even ingested to achieve their effects.  I am concerned about therapeutic concentration, safety, efficacy, and purity as these products are not regulated…. More to come in future blog posts!

Why Don’t We Treat Teeth Like the Rest of Our Bodies? Dental care is excluded from most insurance plans for a bizarre and antiquated reason, and millions of people suffer as a result.

COLLEGE PARK, Maryland—Kira Adam was tired of waiting. When she first noticed the cavity about six months ago, she tried to book a dentist’s appointment, but she had trouble finding a practice that would take her Medicaid insurance.

“Every time I tried to schedule it, it was a two to three month wait” for an appointment, she told me.

The cavity got worse. When she finally did get seen, the dentist told her she would need a root canal. It would cost $1,000, and her insurance would pay nothing.

“He told me to come back when I had the money,” she said. As a baker at Panera Bread, she knew it would be a while before she did. She applied for and received a loan through CareCredit, a medical financing company, but it was a few hundred dollars short. So she waited some more—and tried to ignore the pain that was now shooting through her jaw.

One recent Friday, the wait was over. Or at least, most of it was. She was sitting in the stands of the Xfinity Center at the University of Maryland and looking down on the basketball court, where rows and rows of people were tipped back in dental chairs, getting their teeth fixed as part of a large dental charity event. Adam works at night, so her husband stood in line outside the building from 11:00 p.m. to 7:00 a.m. to secure her spot. Adam drove over straight from work, taking the orange bracelet from her husband’s wrist. The bracelet meant she was in.

It was sad how necessary the Mission of Mercy Dental Clinic turned out to be. A sign outside at 11:00 that morning announced that the day-long event was full and could not accept more patients.

Inside, just beyond the double-doors graced with a “Fear the Turtle” banner, a reference to the university’s mascot, what unfolded was the opposite of a typical American dental visit, with its gentle small-talk and freebie toothbrushes. Here, tired-looking patients sat clustered in groups behind black cloth dividers, their dentists racing by with barely enough time to look up. A seemingly disoriented woman ambled toward me, her mouth stuffed with bloody gauze.

Under the bright gym lights, the patients were nearly elbow to elbow as their doctors worked. The event saw 1,200 patients this year, up from 700 last year. Not everyone could be seen on Friday; about 1,000 were turned away and told to try again the next day.

A tiny 3D printer stamped out new, fake teeth as their future owners waited nearby. In the middle of it all, a choir sang hymns on an elevated stage, lending the whole thing the air of a Greek tragedy.

In the stands, hundreds of people sat waiting their turn. Like Adam, most had been there since the wee hours. The longest line of all was for endodontic services, such as root canals, which can cost thousands and are not covered by Maryland’s Medicaid program.

James Hart drove up from Waldorf, 35 miles away, for a root canal that he has needed for three months. A clinic referred him here after quoting him $1,300.

Rochelle Hernandez, from Laurel, also needed a root canal. She had tried to sign up for dental insurance, but after paying a few other bills, she couldn’t afford the premium. Two weeks ago, she was able to get a dentist to take X-rays of the offending molar by using a discount coupon. But when that office told her it would be $2,000 to fix the problem, she knew she’d be headed to the UMD clinic instead.

Several other people waved me away when I approached them, saying they didn’t feel like talking. I probably wouldn’t have, either, if my teeth were hurting and my only hope of stopping the pain was a day-long wait and a very public drilling.

About a third of people in the U.S. don’t visit the dentist every year, and more than 800,000 annual ER visits arise from preventable dental problems. A fifth of Maryland residents have not visited a dentist in the past five years. Despite the fact that dental procedures are some of the most expensive office visits, dental coverage is treated like a garnish—the parsley of the insurance world.

“Medicaid doesn’t acknowledge that you have teeth unless you’re a child,” said Thomas Ritter, a dentist who was volunteering at the event.

One reason for this is that since the beginning of time, dentistry and medicine have been considered inherently distinct practices. The two have never been treated the same way by either the medical system or public insurance programs. But as we learn more about how diseases that start in our mouths can ravage the rest of our bodies, it’s a separation that’s increasingly hard to rationalize.

The Affordable Care Act, or Obamacare, greatly expanded access to medical care. About 15 million fewer adults are now uninsured. Some gained coverage through the law’s tax cuts for middle-income workers, and others signed up for Medicaid, the insurance program for the poor, which was expanded in about half of states to include people making up to 138 percent of poverty-level income. But dental coverage is not a required benefit under either Obamacare or most Medicaid plans.

The partition between dentistry and the rest of medicine dates back to the dental profession’s roots as an offshoot of hairdressing. Until the 1800s, barbers served as rudimentary dentists, pulling painful teeth and lancing abscesses after they finished trimming whiskers. In earlier centuries, people would see barbers for occasional bloodletting (thought to be therapeutic at the time)—hence the red-and-white striped pole. If there was a flesh wound, the barber could also play surgeon in a pinch. He, after all, was the one with the sharp knives.

“In the early days of medicine, surgery and medicine were two distinctly different professions,” says Burton Edelstein, a professor of dental medicine and health policy at Columbia University and founder of the Children’s Dental Health Project. “This is before anaesthesia, so surgery was rough. It was not regarded as sophisticated.”

For years, Edelstein says, dental students had trouble gaining admission to medical schools, so the first college specifically for dentistry was founded—in Maryland, no less—in 1840.

This minimization of dentistry persisted when Congress was crafting the public health insurance programs in the 1960s. During the original 1965 formulation of Medicaid, the dental market wasn’t very robust and policymakers didn’t value it as highly as other forms of medical care, Edelstein says. In 1960, only 2.3 percent of Americans had some kind of dental insurance.

“Medicaid doesn’t acknowledge that you have teeth unless you’re a child.”
Under Medicaid today, dental care is usually covered only for children and sometimes pregnant women. Just 12 states include the full suite of dental services, including common procedures like crowns and root canals, for Medicaid patients. Three offer nothing at all. The rest provide something in between—usually a list of preventative procedures, like cleanings and X-rays, and sometimes extractions and fillings. Maryland is in this dental middle ground, covering cleanings, fillings, and diagnostics. When it comes to crowns, root canals, bridges, or implants, though, low-income Maryland residents have few options other than paying out of pocket.

“Maryland is on the more generous side,” said Todd Cruse, vice president of government relations for DentaQuest, the company that manages Maryland’s Medicaid dental services.

In other states, dental coverage bobs in and out of the roster of Medicaid benefits as the economy dips and dives. During recessions, Medicaid rolls swell and state budgets contract, so states axe dental benefits in order to save money. After California eliminated most dental benefits in 2009, one woman said she became a vegetarian because meat “gets in these holes in my teeth and it hurts so bad. It’s like migraine pain.” (The state has since restored dental benefits.)

A survey of Medicaid patients in Chicago, Denver, and Portland conducted by the PerryUndem research firm last year found that better dental care was at the top of most beneficiaries’ wish lists.

Better teeth help us socially and financially—one study found that losing one tooth results in a loss of $720 in earnings.

“It is harder to find a job and housing if you have a missing tooth. People judge you if you have missing teeth,” PerryUndem head Mike Perry told me. “I have had participants in other studies say they smile less, and one man grew a beard to hide his missing teeth.”

In extreme cases, the difference between a healthy smile and a diseased one can also mean the difference between life and death.

In January of 2007, a 12-year-old Maryland boy named Deamonte Driver came home complaining of a headache. He grew sicker until he was eventually taken to Children’s Hospital in Washington, D.C. Over the course of several weeks, he endured emergency surgery, a series of seizures, and physical therapy. But just as he began to show signs of recovery, he died during the night. The bacteria from an infected tooth had invaded his brain.

“There are states that will not even provide relief of pain or treatment of active infection just because it’s between the nose and the chin,” Edelstein says.

According to him, health plans should regard incisors like they do kidneys—or any other part of the body. The gap between dentistry and medicine, he says, “has been a lasting, physiologically, medically, morally, and ethically inappropriate separation.”

* * *

To make matters worse, dental insurance is uniquely confusing. When I emailed Maryland’s Medicaid program to find out why so many of its beneficiaries were getting their teeth pulled on a basketball court, they send me this chart.

It outlines the eight MCOs, or managed care organizations, that Medicaid recipients must choose from, each of which offers a slightly different suite of benefits. “Dental” sits in part of the chart titled, “Additional Benefits,” right under a heading that warns: “MCOs ARE NOT REQUIRED TO OFFER THE SERVICES LISTED BELOW. THE SERVICES LISTED BELOW ARE OPTIONAL AND CAN BE CHANGED OR DISCONTINUED AT ANY TIME.” All of the MCOs are currently “voluntarily providing a limited benefit,” for dental care—but they can stop whenever they want. Their benefit descriptions are similarly vague, claiming to provide “limited extractions” or “limited fillings.”

Living Poor and Uninsured in a Red State
Maryland’s health agency eventually answered all of my questions. But many low-income people, who already endure the stresses of living on a fixed income, who may not have much experience with health insurance, and who may not be free to place phone calls between the MCO operating hours of 8:00 and 5:00, would likely have a harder time navigating this labyrinth.

“Dental care is particularly confusing and few seem to know what, if any, dental services beyond extractions are covered by Medicaid,” the PerryUndem report found. One woman told the researchers that it seemed odd that she was covered for having a rotten tooth yanked out, but not for a dental cleaning.

Indeed, several people I met at the dental clinic seemed fundamentally perplexed about how dental insurance would work, if they had it. A woman named Crystal, also from Waldorf, needed three fillings and hasn’t gone to the dentist in years. She qualifies for insurance through her job at Macy’s, and she at first attributed her lack of insurance to “procrastination.” Later, though, she admitted that it seemed expensive, and that people had told her it would cost more to have dental insurance than to simply pay out of pocket, but she wasn’t sure.

An older woman named Cheryl, who had been in line since 2:00 a.m., had broken a tooth three weeks ago and was now living with “a raw, open nerve.” She said she just qualified for Medicare, the health insurance program for seniors, and she hopes to enroll soon. Then she paused a minute.

Under Medicare, “I don’t know if dental is included,” she said. (It’s not.) By comparison, she said, the UMD clinic seemed like a good option. “For free? I’m prepared to wait. I would stand on one leg.”

Even in states that do offer dental benefits for poor adults, Medicaid patients often have trouble getting appointments because most dentists either do not accept Medicaid patients or limit the number of Medicaid appointments they will schedule.

In general, a good dentist is hard to find: There are about 4,000 designated dentist shortage areas all over the U.S. In some of the worst-affected states, between a quarter and a third of the population lacks access to dental care entirely. In sparsely populated states like Vermont, Maine, and Wyoming, nearly half of dentists are nearing retirement.

Deamonte Driver’s death was partly attributed to periodic lapses in his coverage under Medicaid, but also to the difficulty his mother faced in finding a dentist who would accept Medicaid patients. The program’s reimbursement rates to providers are much lower than those of private insurance plans.

In a report on the national shortage of dentists, the Pew Charitable Trusts argued that not even boosting Medicaid rates or easing the Medicaid paperwork burden for dentists would resolve the crisis entirely.

The situation is most dire in states that don’t offer any dental care at all to poor people. In Tennessee and Alabama, which don’t provide any dental services for low-income adults, seniors are more likely to have lost all of their natural teeth.

The states’ perspective is understandable, of course. Dentistry is bespoke: It’s not like antibiotics or insulin. Every mouth is unique, and teeth are hard to replace. You could see how a cash-strapped state might be reluctant to throw money at a problem that’s both expensive and, unless it involves the front few teeth, largely invisible.

Invisible, that is, until it materializes as a line of people waiting to get their cavities filled in a college athletic center.

Oral manifestations of Celiac Disease: Dentists be Aware!

Clinical suspicion of celiac disease

By Christopher Friesen

celiac disease dental enamel defects

According to a study1 published in 1989, people with celiac disease (CD) have a higher risk of developing oral cancer if they are not on a gluten-free diet. If dental professionals know more about celiac disease, and how this illness affects the entire person, including the mouth, they can help in its early detection, and possibly help their patients avoid years of suffering.

When Connecticut-based dentist Dr. Ted Malahias’s wife and daughter were diagnosed with celiac disease, their pediatric gastroenterologist asked to see his daughter’s teeth. Dr. Malahias knew diseases of the digestive system could manifest with symptoms in the mouth, but a link between CD and problems with teeth was new to him. Wanting to know more, he looked for research that might explain the connection.

It wasn’t easy to find. The North American medical establishment is not as knowledgeable about CD as other medical establishments in the world. There were several European studies that had linked dental enamel defects to celiac disease — that’s how his daughter’s doctor had known to check her teeth. CD is much better understood in Europe and other parts of the world than in the U.S.

“They’re more aware of celiac disease because the connection between CD and the mouth was in the literature from 1990,” Dr. Malahias said in a phone interview. “They are trained, especially in Italy, and they are more attuned to it than we are here.”

As he researched this connection more, Dr. Malahias contacted Peter Green, M.D., a researcher at Columbia University’s Celiac Disease Center.

“When I called him, he already knew there was a connection between celiac disease and dental enamel, but there were no papers here and he wanted to do a paper for the U.S. literature,” he said.

During that phone call, Dr. Green recruited Dr. Malahias to perform the study with the goal of linking the occurrence of dental enamel defects to CD. Dr. Malahias is a practicing dentist, not a clinical researcher or an academic, but Dr. Green needed help with conducting the study, and Malahias agreed.

“It was more of a give-back,” Dr. Malahias explained. “He said ‘do you want to do this study?’ and I said, ‘yes’ because there’s a need for it. The goal was to get that one statement out that there’s a connection between dental enamel defects and celiac disease, and that doctors need to look for it.”

To develop that conclusion, Dr. Green put Dr. Malahias in touch with celiac disease support groups. Dr. Malahias attended group functions and recruited patients and control subjects. He conducted an examination of all subjects’ mouths and documented their history of aphthae. He photographed their teeth and graded the amount of enamel defects. As part of the study, Dr. Malahias asked a second dentist to examine the photographs to check his conclusions.

Dr. Malahias then passed his research along to Dr. Green, who had statisticians crunch the numbers. Other members of the research team wrote the final paper, which was published in the Journal of Gastroenterology in 2009.2

After examining the evidence, the study revealed two main findings:

1. CD is highly associated with dental enamel defects in childhood.
2. There is an association between CD and aphthous ulcers.

The dental enamel defects appeared in childhood, the authors theorized, due to the onset of CD during enamel formation. The adults in the study did not show this same association. This may seem unusual, until the manifestation of CD is fully understood. Unfortunately, Dr. Malahias admits, his colleagues don’t yet know enough about CD.

“I think they are more aware of it, but I think more has to be done to get the word out so they know the details,” he said.

So what do dentists and other dental professionals need to know about celiac disease? According to Dr. Malahias, “Everything. They really don’t know the details. They need to understand that it’s not just an allergy, and they have to understand that the people are really ill.”

What is celiac disease?

Many breakthroughs in CD research have happened during the last 20 years, but the condition is an ancient one, well documented back to the first century A.D. Aretaeus of Cappadocia, a Greek physician, described the condition and named it Koiliakos after the Greek word for abdomen, “koilia.” Aretaeus understood that properly digested food was assimilated into the body somewhere in the stomach organs, and something prevented that process among his affected patients.

Eighteen hundred years later, several physicians treating children with the illness would lay the foundation for a modern understanding of the disease and its treatment.

Samuel Jones Gee, Christian Archibald Herter, and Willem Karel Dicke were some of the early pioneers in the field. At one time the condition was known as Gee-Herter disease in acknowledgement of the first two. Willem Karel Dicke is credited with pioneering the gluten-free diet as the treatment for the condition in the late 1930s and early 1940s.

Today, researchers such as Columbia’s Dr. Peter Green and Dr. Alessio Fasano of the Center for Celiac Research at Mass General Hospital for Children in Boston (formerly at the University of Maryland School of Medicine) are leading the research effort. Dr. Fasano is widely regarded as an expert in the field. In 2003, his research team published the results of a landmark study3 that showed that one in 133 North Americans is affected by CD.

Dr. Fasano’s study defines CD in clinical terms: “Celiac disease is an immune-mediated enteropathic condition triggered in genetically susceptible individuals by the ingestion of gluten.”

As Dr. Malahias said, it’s not an allergy. Rather, it is an autoimmune disorder that causes villous atrophy in the small intestine when ingested gluten produces an immune response that doesn’t attack the gluten, but instead attacks the intestine.

“The gluten is deamidated by tissue transglutaminase, which allows interaction with HLA-DQ2 or HLA-DQ8 on the surface of antigen-presenting cells,” Dr. Malahias said. “Gliadin is presented to gliadin-reactive CD4+T cells through a T receptor, resulting in production of cytokines that cause tissue damage.”

In a healthy intestine, food is broken down by the villi. Beneath them, enterocytes work on absorbing nutrients and passing them into the bloodstream. If the body encounters a particle that requires an immune response, the enterocytes pass the immune system’s cells into the intestine. Normally the enterocytes are packed tightly against one another and should remain that way.

Ingested gluten is naturally difficult to digest and, in genetically susceptible individuals, it is treated as a foreign body. The enterocytes release a chemical that loosens those tight molecular junctions between themselves, creating what Dr. Fasano refers to as a “leaky gut.” Once the junctions are loosened, gluten particles can penetrate through to the layer of immune cells under the enterocytes, which triggers the autoimmune response attacking the enterocytes and causing the villous atrophy.

What are the symptoms?

Celiac disease has a variety of classical symptoms relating to problems with the gastrointestinal tract. Symptoms including diarrhea, intestinal bloating, and cramps, and these are often the first, most urgent responses to gluten ingestion. Other symptoms can include irritability and weight loss as the body’s nutrient uptake system fails.

Anemia and other nutrient deficiencies are commonly related to untreated CD. Many of these symptoms mimic other conditions such as irritable bowel syndrome, lactose intolerance, or diverticulosis, which can add to the complications in diagnosing CD. In children, lack of nutrient absorption may cause delays in growth and the onset of puberty, vomiting, irritability, changes in behavior and, of course, problems with the enamel on their teeth.

According to Dr. Fasano’s study, CD has a prevalence of approximately 1 in 133 people. First and second degree relatives of diagnosed individuals have a 1 in 22 chance and 1 in 39 chance respectively of also having CD.

CD can remain largely dormant for many years, but among genetically susceptible individuals it can appear at any time during their lives. Stress, pregnancy, surgery, or even infections may cause the onset of severe symptoms. CD does not discriminate and occurs on all continents, and among all racial, cultural, and age groups.

How is celiac disease diagnosed and treated?

Several blood tests have been developed to help screen for CD. Testing serological samples for anti-gliadin antibodies, the AGA test; endomysial antibodies, the EMA test; anti-tissue transglutaminase antibodies, the anti-tTG test; and deamidated gliadin peptide antibodies, the DGP test, can all be used to support a diagnosis and the need for further testing. But there is only one conclusive test that physicians rely on — conducting an intestinal biopsy and examining the damage to the villi.

Diagnosis can be difficult, and many celiac associations report that some people have sought the help of three or more doctors, and spent several years suffering before finally being diagnosed.

CD is unusual in the spectrum of autoimmune disorders because of what is known about it. Dr. Fasano’s research has revealed the three main ingredients in the disease pathogenesis:


  1. Genetic susceptibility
  2. Leaky gut
  3. Environmental trigger (gluten)

Remove any one of these three and the condition should go away. Researchers are working on drug therapies to plug the leaky gut, but there is currently only one known treatment for CD – eliminating the environmental trigger by maintaining a strict adherence to a gluten-free diet. Any ingestion of gluten will cause illness, and as the 1989 study showed, continued ingestion increases the chance of other diseases developing.

Gluten is the combination of two proteins, glutenin and gliaden, that occur in cereal grains such as wheat, barley, and rye. Glutenin and gliaden exist independently within the whole head of the grain, but become combined into gluten when moisture is added.

When cereal grain flours are mixed with water to form dough, the combined proteins form into longer chains of stretchy molecules. Gluten provides the structure and support for trapping gasses during the rising process. Baking dries and sets the final product, but the gluten remains.

Gluten itself can be extracted from grain, and has been developed into a commercially available product that may be used as an additive in a variety of items including food, cosmetics, and dental hygiene products.

How can dental professionals respond?

Dr. Malahias says dental product companies have responded well to the need for gluten-free, and if patients or dentists aren’t sure, they can check the labels on their inventory.

“Everything is labeled now,” he said. “Before, you had no idea what was in a lot of polishing pastes. Now they are labeled gluten-free, preservative-free, saccharine-free. They list this. They specifically list gluten-free now.”

Dr. Malahias also recommends that dentists add celiac disease to their medical history questionnaires. He says all patient questions should be treated seriously, and all concerns should be addressed with the understanding that these people are suffering from a very serious illness.

“The last thing [a patient] wants is to get sick again by something you put in their mouth,” he said.

Dr. Malahias now speaks around the country, telling other dental professionals about the connection confirmed by his study. He has also started appearing at celiac education events to further get the word out. He is very interested in seeing his peers become knowledgeable on this subject because their clinical suspicions may be the first step in directing patients to physicians who can properly diagnose, or rule out, CD.

“Because we see the tissue and we see the health of the tissue, we can advise patients to go see their physicians,” he said. “[Dentists] can’t diagnose celiac disease, and you can’t say everyone with dental enamel defects has celiac, but you should at least think about it.”

Dr. Malahias’s complete study and more information on celiac disease and the dental patient can be found on his office’s website at

Christopher Friesen is a professional technical and freelance writer. His work has appeared in Connector Specifier Magazine, The Journal of Commerce, the Winnipeg Free Press, and Radio World Magazine. He and his wife publish the gluten-free recipe website,


1. Holmes GK, Prior P, Lane MR, Allen RN. “Malignancy in celiac disease – effect of a gluten-free diet.” Gut, 30(3):333-338; 1989.
2. Cheng J, Malahias T, Brar P, Minaya MT, Green PH. The association between celiac disease, dental enamel defects, and aphthous ulcers in a United States cohort. J Clin Gastroenterol. 2010 Mar;44(3):191-4. doi: 10.1097/MCG.0b013e3181ac9942.
3. Fasano A, Berti I, Gerarduzzi T, et al. Prevalence of celiac disease in at-risk and not-at-risk groups in the United States: a large multicenter study. Arch Intern Med. 2003 Feb 10;163(3):286-92.