GERD and Tooth Erosion

What Is Gastroesophageal Reflux Disease?

GERD, also called gastroesophageal reflux disease, is caused due to the lack of coordination or failure in the coordination of the anti-reflux mechanism of the lower esophageal tract. The lower esophageal sphincter controls the retrograde movement of the acid. There is a physiologic retrograde content flow in gastroesophageal reflux disease, which usually occurs after meals and may have esophageal and extraesophageal symptoms, causing systemic and mental health afflictions. When the retrograde movement occurs quite frequently in persons or individuals suffering from chronic GERD, the quality of life gets significantly impaired owing to the multifarious detrimental effects caused by frequent gastroesophageal reflux onto the immune, oral, and general systemic health. GERD incidence is higher in individuals aged 40 and above. It is not uncommon for adults or children of any age, given the causative factors, to suffer from this condition and the wide geographical prevalence.

What Is Dental Erosion?

Tooth-related erosion or dental erosion is a condition caused not by bacterial attack or action. It is caused by extrinsic and intrinsic factors, making it a severe regressive tooth alteration. The loss of tooth enamel, dentin, and the cementum layer is indeed irreversible.

• Intrinsic Factors: It may be due to intrinsic factors, the main causative being a regurgitation of acid reflexes, anorexia, bulimia, stress-related acid reflux, alcohol abuse, and psychosomatic disorders.

• Extrinsic Factors: Extrinsic factors like frequent exposure to chewable vitamin C tablets, sports drinks, acidic foods, and soft drinks containing high acidic content (acidic beverages) predominantly affect the enamel surface.

Dental erosion is definitely more prevalent and visualized on routine dental examination and in the case of gastroesophageal reflux disease, particularly on the palatal and lingual surfaces of the affected teeth. Apart from tooth erosion, halitosis or bad breath, and oral mucositis or inflammation of the soft tissues of the oral cavity would be common.

How Is Tooth Erosion Related to GERD?

GERD can be caused either due to stress-induced vomiting or acid reflux, regurgitation issues caused by psychosomatic health problems, or even a history of alcohol abuse that aggressively worsens over time. Though the common symptom of GERD remains heartburn for most patients, during a routine dental examination or check-up, dental enamel erosion is one of the common finds to prove the existence of this chronic condition.

The evidential documentation of researchers over the last few years have linked a strong connection between GERD and enamel erosion that, in turn, causes the sequel of tooth decay. Dental surgeons can clearly observe the ill effects of GERD onto the hard enamel structure compared to the less pronounced but disturbing effects on the oropharyngeal mucosa, esophagus, and even the respiratory tract.

As mentioned earlier, GERD remains an intrinsic cause of dental erosion. So the pathophysiology of erosion is because of the lowering of critical pH, which can dissolve the strong hydroxyapatite crystals of the tooth enamel (critical pH level is 5.5, and in this case, it is lowered below this range to almost below 2.0).

Children affected by this GERD disease are at an even higher risk as the enamel in children is more prone to bacterial colonization and a faster rate of decay and has a higher risk of developing carious lesions than healthy children.

Sleep-Related GERD vs. Waking GERD:

Almost 40 to 90 % of individuals suffering from gastroesophageal reflux report a prevalence or history of vomiting in non-REM sleep or the sleeping or nocturnal phase as well. However, these reflux episodes in sleep may last 15 to 20 minutes, which is higher comparatively against the 1 to two minutes of gastric emesis in the waking state. Sleep-related GERD also poised risk of acid exposure to the esophageal tract resulting in a lowered pH below 4.0, causing psychologic and gastric disturbances to the patient.

The prone position in sleep-related gastroesophageal reflux is also associated with the proximal migration of the gastric contents that are erosive to the tooth enamel. The gastric contents will eventually displace the saliva from the tooth surface or the enamel of the tooth surface specifically (displacement of saliva and proteolytic pepsin along with the protective dental pellicle).

What Are the Risk Factors for GERD?

The risk factors for either sleep-related or waking GERD is multifactorial and may be caused due to any of these underlying conditions or causes:

• Chronic alcohol consumption.

• History of or a patient suffering from alcohol abuse.

• Obesity.

• Obstructive sleep apnea (OSA).

• Frequent exposure to nicotine.

• Frequent intake of caffeine.

• Pregnancy.

• Hiatal hernia.

• Certain medications can impact intra abdominal pressure.

• Intestinal obstruction or intestinal disease.

• Frequent consumption of spicy and acidic foods or acidic beverages.

All the above-mentioned risk factors predispose the patient to develop a transient increase in the intraabdominal pressure gradient leading to lower esophageal sphincter incompetence.

What Are the Symptoms of GERD?

The clinical symptoms for these patients mainly include:

• Heartburn.

• Regurgitation of acids causes a sour taste in the mouth.

• Frequent or recurrent nausea and vomiting.

The less common symptoms reported by GERD cases are:

• Chronic coughing.

• Hoarseness in the voice.

• Burping.

• Pain while swallowing food or odynophagia.

• Difficulty swallowing food or dysphagia.

• Increased salivary secretions during the episodes of GERD.

How Is GERD Diagnosed?

After a detailed assessment of the patient’s clinical symptoms, the gastroenterologist may suggest a diagnostic PPI (Proton pump inhibitor) test, esophageal pH monitoring, or upper endoscopy.

How Is GERD Managed?

1. Systemic Management:

To relieve clinical symptoms of GERD, the gastroenterologist may give over-the-counter antacids, proton pump inhibitor drugs, lifestyle changes, and H2 blocker drugs. However, in case of severe and recurrent symptoms impacting systemic and general health and lifestyle, laparoscopic fundoplication surgery and bariatric surgery are surgical options effective in the long-term management of this condition.

2. Dental Management:

Dental management mainly includes restorative treatment of severely eroded teeth and lifestyle changes, especially tooth brushing, avoiding acidic foods and drinks, and also promoting the salivary flow secretions (by salivary stimulating supplements or mouthwashes for xerostomia or dry mouth) as it acts as a protective barrier for tooth enamel and prevents erosive lesions further. Maintenance of oral hygiene and regular dental check-ups, including prophylactic and restorative treatments, will benefit the patients suffering from GERD.

Conclusion:

To conclude, it is pivotal that the gastroenterologist and dental surgeon coordinate for treating the patients suffering from GERD for long-term management. Lifestyle changes and treatment of underlying causes will aid in a better prognosis of this condition.