Erosive Tooth Wear and Gastroesophageal Reflux Disease: An Interdisciplinary Management for a Relevant Dental Problem

Abstract

Gastroesophageal reflux disease (GERD) is a frequently occurring digestive disorder resulting in acid reflux into the oral cavity. Apart from its esophageal symptoms, it also manifests in the mouth, with erosive tooth wear (ETW) being the most encountered oral affliction. ETW is a cumulative and irreversible condition; if it remains unrecognized, it progressively worsens over time, significantly impacting the quality of life and imposing a substantial economic burden, especially when associated with untreated GERD. Early identification and timely intervention are essential to preventing disease progression and minimizing long-term consequences. An interdisciplinary approach that integrates medical and dental care offers the most effective management strategy. Preventive measures, including lifestyle and dietary modifications, patient education on appropriate oral hygiene, and the application of fluoride, play an important role in mitigating ETW risk. This paper explores the pathophysiological link between ETW and untreated GERD, focusing on its etiology, clinical presentation, and diagnostic considerations. It also examines the economic burden of untreated ETW and discusses the potential of emerging technologies, like artificial intelligence, digital and teledentistry in improving early detection and tailored treatment. Additionally, the review outlines effective management strategies aimed at improving clinical outcomes and ensuring comprehensive patient care.

Keywords: acid reflux; dental erosion; erosive tooth wear; gastroesophageal reflux disease; teledentistry.

Figure 1. Pooled frequency of ETW in patients with GERD in different regions of the world

Adapted and recreated from reference [15] ETW: Erosive tooth wear; GERD: Gastroesophageal reflux disease; OR: Odds ratio; n: number of studies.

Figure 2. Pathophysiology of ETW in patients with GERD

Adapted and recreated from references [5,8,21] Salivary pellicle is removed by repeated acid attacks, which allows the acid to come into direct contact with the tooth surface. Since acid has a lower surface tension than saliva, it easily displaces the saliva and contacts the tooth surfaces. This creates an open system where the tooth surface undergoes demineralization as tooth substance is lost into the oral environment. On the enamel surface, the acid, along with its hydrogen ion (or a chelating agent), starts to dissolve the enamel crystal. This process begins in the prism sheath area and then affects the prism core and the interprismatic areas, leading to the outflow of mineral ions from tooth surface. Consequently, there is a rise in local pH within the tooth substance and in the liquid layer near the enamel surface. This results in a honeycomb appearance or dished-out lesion on the enamel surface. The erosive process is halted in the absence of further acid exposure. ETW: Erosive tooth wear; GERD: Gastroesophageal reflux disease.

Figure 3. Clinical manifestations of GERD and tools for their assessment

Adapted and recreated from references [32-35] ETW: Erosive tooth wear; ECG: Electrocardiogram; EGD: Esophagogastroduodenoscopy; GERD: Gastroesophageal reflux disease.

Figure 4. Clinical manifestations of ETW and tools for their assessment

Adapted and recreated from references [5,9,35,36] ETW: Erosive tooth wear, BEWE: Basic Erosive Wear Examination

Figure 5. Multidisciplinary approach for prevention and management of ETW in GERD patients

Adapted and recreated from references [8,40,54,55] ETW: Erosive tooth wear; GERD: Gastroesophageal reflux disease

Figure 6. Strategies to manage ETW associated with GERD

Adapted and recreated from references [54-60] ETW: Erosive tooth wear; GERD: Gastroesophageal reflux disease

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