Gastroesophageal reflux disease and tooth erosion

Abstract

The increasing prevalence of gastroesophageal reflux disease (GERD) in children and adults, and of "silent refluxers" in particular, increases the responsibility of dentists to be alert to this potentially severe condition when observing unexplained instances of tooth erosion. Although gastroesophageal reflux is a normal physiologic occurrence, excessive gastric and duodenal regurgitation combined with a decrease in normal protective mechanisms, including an adequate production of saliva, may result in many esophageal and extraesophageal adverse conditions. Sleep-related GERD is particularly insidious as the supine position enhances the proximal migration of gastric contents, and normal saliva production is much reduced. Gastric acid will displace saliva easily from tooth surfaces, and proteolytic pepsin will remove protective dental pellicle. Though increasing evidence of associations between GERD and tooth erosion has been shown in both animal and human studies, relatively few clinical studies have been carried out under controlled trial conditions. Suspicion of an endogenous source of acid being associated with observed tooth erosion requires medical referral and management of the patient as the primary method for its prevention and control.

Figure 1

Pattern of sleep-related esophageal acid exposure in a patient with erosive esophagitis. Night-time acid reflux during supine sleep leads to pH levels <4 that are continuous and sustained. (Reproduced Figure 2, page 111S, from Orr [26]. With copyright permission from Elsevier).

Figure 2

When dental pellicle is removed by sustained endogenous acid attacks, then demineralized tooth products are lost to the oral environment. HA: hydroxyapatite. (Amended Figure  2.5, page 15, from Smales et al. [67]. With copyright permission from Jaypee Medical Publishers 2011.)

Figure 3

Frontal and maxillary occlusal views of severe tooth erosion caused by endogenous acid in a patient with GERD. (Courtesy of Dr. A. Dickson.)