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Dental relevance of GERD (gastro-esophageal reflux disease)

Introduction Many systemic diseases exert their influence on oral health. Among these, Gastroeosphageal Reflux Disease (GERD) is one of the most common. The increasing prevalence of GERD in both adults and children increases the responsibility of dentists to be alert to the oral manifestations of this disease and to take the appropriate precautions and considerations when treating these patients.

1.	 Oral manifestations 

GERD is one of many diseases which affect our oral health. Many studies conducted over the years have found reasons which support this statement. In a recent study of 100 patients diagnosed with GERD, over 10% of the patients had teeth erosion, a condition where the surface of their teeth is eroded and loss permanently. Most of these patients are older patients and have been diagnosed with GERD for many years. As the GERD becomes more severe, so does the severity of tooth erosion in these patients. Acid reflux into the oral cavity can cause dissolution of the enamel, especially at the palatal surfaces of posterior teeth. Other manifestations of GERD in the oral cavity include xerostomia, acid or burning sensation in the mouth, halitosis and erythema of the palate and uvula caused by the presence of acid in the oral cavity.2 Other not so common symptoms of GERD include difficulty in swallowing, also known as dysphagia, water brash which is flooding of the mouth with saliva, pain on swallowing, chronic cough/ hoarse voice, nausea and vomiting. Severe forms of GERD has been linked with Barrett’s oesophagus. It is a condition in which the cells of the oesophagus undergo metaplasia. Barrett’s oesophagus is one of the risk factors for oesophageal adenocarcinoma which has poor prognosis and high mortality rate.

Besides, saliva is one of the main protection of our teeth, the mucosa of the oropharynx and of the oesophagus. Proton pump inhibitors (PPIs), a drug which is commonly given in patients who have GERD to suppress the amount of acid produced in the stomach can actually cause hyposalivation, a condition where there is decreased amount of saliva in the mouth, thus having less protective effect on the structures in our oral cavity.

Severe, long-standing GERD was found to negatively affect our teeth, oral soft tissues and also saliva amount which is detrimental to our overall dental health.

2.	 Dental considerations 

Dentists are often the first healthcare professional in detecting several systemic health issue by their oral manifestations, including GERD. Early recognition of such manifestations is crucial to stop the progression of dental erosions. Furthermore, dentists should also carry out a thorough examination and history taking to address the dental implications of the GERD symptoms. It should include medical history, dietary history, occupational and recreational history, dental history as well as intraoral examination, head and neck examination, and assess salivary functions.

Medical history: It should emphasise on any symptoms of gastric reflux including history of vomiting, previous investigations carried out to evaluate the gastro-intestinal complaints and the relevant drug history. Dentist shall then evaluate the patient’s relevant symptoms such as belching, heartburn or acidic taste in mouth and consider for a referral to a physician.

Dietary history: Dietary habits that may lead to dental erosions such as frequent consumption of soft drinks and acidic citrus fruits shall be questioned specifically in order to rule out other underlying etiological factors of dental erosions.

Occupational and recreational history: It is also important to obtain information regarding patient’s occupation as workers who had contact with acids (such as those working in acid fumes, battery factory and professional wine tasters) may show increased risk of getting dental erosions.

Intraoral examination: It is of utmost importance to differentiate erosion from other lesions such as abrasion, attrition and abfraction beside evaluating its progression. Typical signs of enamel erosion on buccal and lingual sites are the appearance of a smooth, silky-glazed, sometimes dull, enamel surface with the absence of perikymata, together with intact enamel along the gingival margin. Erosive tooth wear can involve any surface of the teeth, but it is most commonly seen on the facial, occlusal, and lingual surfaces. Once dentin is exposed, the loss of dentin progresses faster than the loss of enamel, such that “cupping” of lesions on the occlusal surfaces occurs. Dental erosions resulting from GERD initially occur on palatal surfaces of maxillary teeth then the occlusal surfaces of mandibular molars, followed by the labial or buccal surfaces due to the contact with refluxed acid.

Dental history: It will be evident in patients with restorations as tooth structure typically dissolves much faster than the restorative material, causing it to seem as if it “stands above” the surrounding tooth structure.

Salivary function: Check for any reduction in the loss of saliva secretion as it may contribute to the progression of enamel erosion. Diagnostic kits are available to check for several salivary parameters, including the pH and buffering capacity.

Prevention and management of dental erosions: First step is to identify the source of dental erosions by ruling out any other possible etiological factors. Then preventive measures should be carried out by reducing intake of acidic food and drinks, increasing fluoride level and improving salivary flow rates. Restorative treatment could also be considered for patients with severe tooth loss.

Selection of dental restorative materials used in managing dental erosion is multifactorial, depending on analysis of remaining tooth structure, amount and location of tooth loss, and occlusion. The patients affected by severe erosive destruction need complex occlusal rehabilitation. The placement of extensive restorations like porcelain veneers only and full veneer crowns is utilized. Besides that, direct acid-etched composite can also be used as a restorative material for less severe erosions. Direct composite restorations are recommended for vertical dimension loss of less than 2 mm, while indirect ceramic veneer and overlays are recommended for more than 2 mm loss in vertical dimension. Post- treatment follow-up and counseling are also recommended to ensure a favourable prognosis of these restorative procedures.

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