Perio-Nutrition - Clinical Nutrition for the Dental Team
Feature Article 

Gastro-oesophageal Reflux Disease and Oral Health
© Juliette Reeves 2010 

Gastro-oesophageal Reflux Disease (GERD) is a disorder in which there is recurrent return of stomach contents back up into the oesophagus, frequently causing heartburn and irritation of the oesophagus by stomach acid. This can lead to scarring and stricture of the oesophagus. It is estimated that 10% of patients with GERD develop Barrett's oesophagus which increases the risk of cancer of the oesophagus, and 80% of patients with GERD also have a hiatus hernia. 

Gastro-oesophageal reflux disease results from the reflux of gastric contents, causing symptoms or injury to oesophageal tissue.(1,2).  GERD symptoms represent 
one of the most frequent health problems in the Western world (3). Indeed, depending on the population studied, the prevalence of the primary GERD symptoms such as heartburn (i.e. a burning feeling behind the breastbone) or acid regurgitation (i.e. an acid taste in the mouth) varies between 9% and 42%.(4,5). Despite the high prevalence of GERD symptoms, however, its aetiology is still not completely understood (2). It is estimated that between 10-15% of UK  adults suffer from heartburn weekly (6). A further  study has  also shown that being above normal weight substantially increases the likelihood of suffering from heartburn and acid regurgitation and obese people are almost three times as likely to experience these symptoms as those of normal weight.(7). 
The association of gastro-oesophageal reflux disease with dental erosion has been established in a number of studies in adults. Symptoms of reflux are listed in Table 1.  However, GERD can also be "silent" with the patient unaware of his or her condition until dental changes cause assessment for the condition(8). Dental erosion associated with GERD also occurs in children and may be an initial finding in this gastric condition (11,12). GERD in children can occur from infancy through the teenage years.  Table 1 also lists common symptoms of GERD in children.  Several studies have reported erosion of primary and permanent teeth in children with GERD making this an oral health concern in both children and adults. 
Although the symptoms of gastro-oesophageal reflux disease are common in the general adult population, the aetiology of gastro-oesophageal reflux disease is still largely unknown. Lifestyle factors such as diet, body mass index, and smoking have been frequently suggested as possible risk factors.
Enamel erosion is defined as being a progressive loss of hard dental tissue by chemical processes not involving bacterial action (13).  The clinical appearance includes:            
    * Broad concavities within smooth surface enamel
    * Cupping of occlusal surfaces, (incisal grooving) with dentin exposure
    * Increased incisal translucency
    * Wear on non-occluding surfaces
    * "Raised" amalgam restorations
    * Clean, non-tarnished appearance of amalgams
    * Loss of surface characteristics of enamel in young children
    * Preservation of enamel "cuff" in gingival crevice is common
    * Hypersensitivity
·   * Pulp exposure in deciduous teeth
Erosion of the enamel surface can be the result of a number of confounding factors which can be broadly divided into two main groups: extrinsic and intrinsic factors. Extrinsic factors include acid based food and drinks, medications that create an acid environment in the mouth and  exposure to environmental acids. The most common of these are dietary acids found mainly in fruit and fruit juices with a low pH. Carbonated drinks and sports drinks are also very acidic.  Several studies have found that the frequency of consumption of acidic drinks was significantly higher in patients with erosion than without (14,15). This finding is of concern, particularly since children and adolescents are the primary consumers of these drinks (16). Less common sources of extrinsic erosive acids are related to occupational and recreational exposure . 
Intrinsic Acids
When gastric acids, (with pH levels that can be less than pH1), reach the oral cavity and come in contact with the teeth, erosion of the tooth surface will occur. This is particularly so in conditions such as gastro-oesophageal reflux and excessive vomiting related to eating disorders.
The role of gastro-oesophageal reflux disease in dental erosion has been widely reported (17). Regurgitated acid entering the mouth causes dental erosion. The pattern of erosion is similar to that in other conditions involving stomach juice, such as eating disorders, rumination, and chronic alcoholism. Bartlett et al (8), in a controlled study, investigated 36 patients with palatal dental erosion. The results were compared with those from ten subjects with neither tooth wear nor symptoms of gastro-oesophageal reflux disease. Oral pH was also measured simultaneously. Twenty-three (64%) patients were found to have gastro-oesophageal reflux disease. A statistically significant relationship was observed between the pH in the distal oesophagus and the pH in the mouth.
Recent study has also reported that children with GERD have more erosion and dental caries compared to healthy controls and should be targeted for increased preventive and restorative care (18,19). For every subject enrolled in the study, a healthy control sibling without the condition was recruited. Medical histories were obtained from medical records, and dental and dietary histories were obtained from parents. The teeth were examined for erosion, dental caries, and enamel hypoplasia, and sampled for Streptococcus mutans. Although there were more subjects with Streptococcus mutans in the GERD group compared to the control group (42 per cent vs 25 per cent), the difference was not statistically significant. 
Patterns of Erosion
The pattern of erosion due to intrinsic factors has also been observed as being distinct to that of extrinsic acids. It has been suggested  that lingual cervical lesions associated with incisal erosion on the mandibular anterior teeth are strong discriminators between tooth wear in patients with bulimia nervosa or chronic gastro-oesophageal reflux and those whose dental erosion is due to extrinsic acids (20. An additional  study also suggest that gastro-oesophageal reflux is strongly associated with palatal erosion and that some patients presenting with palatal dental erosion should be assessed for gastro-oesophageal reflux as a possible cause, even in the absence of clinical symptoms of reflux.(21,22).
 The relationship between dental erosion, soft drink consumption, and gastro-oesophageal reflux was also investigated in young adults aged 19-22years (23). No significant difference was observed in the prevalence of dental erosion between young adults and GERD patients. However, by combining the two study groups a three-fold higher risk of having erosion in molars or incisors was found for subjects drinking Coca-Cola three times a week or more often ( p < 0.05). Additionally, significantly higher erosion scores were found in molars among subjects drinking more than 1 litre of carbonated drinks (all brands) per week ( p < 0.05). It is concluded that the frequency of soft drink consumption is a strong risk factor in the development of dental erosion.
Taking a  thorough medical history may reveal symptoms of GERD which may assist dental professionals in the correlation of erosion with this systemic condition.
Treatment of GERD usually begins with head elevation (extra pillows during sleep), dietary modification (avoiding spicy or fatty foods) and the use of antacids. Antacids were the standard treatment in the 1970s and are still effective in controlling mild symptoms of GERD. Antacids should be taken after each meal and at bedtime. Other medications include:
          o Histamine H2 receptor antagonists are the first line agents for patients with mild-to-moderate symptoms. Histamine H2 receptor antagonists are effective for healing only mild oesophagitis in 70-80% of patients with GERD and for providing maintenance therapy to prevent relapse. 
o Additional H2 blocker therapy has been reported to be useful in patients with severe disease (particularly those with Barrett oesophagus) who have nocturnal acid breakthrough.
          o Proton pump inhibitors are the most powerful medications available. They are used only when GERD has been objectively documented. Proton pump inhibitors work by blocking the final step in the H+ ion secretion by the parietal cell. They have few adverse effects and are well tolerated for long-term use.
          o Prokinetic agents improve the motility of the oesophagus and stomach. These agents are somewhat effective but only in patients with mild symptoms; other patients usually require additional acid-suppressing medications such as proton pump inhibitors. Long-term use of prokinetic agents may have serious, even potentially fatal, complications and should be discouraged. (24).
Lifestyle factors
Lifestyle factors - in particular overweight, obesity and smoking – have been associated with increased reflux symptoms). Various lifestyle factors are thought to be associated with GERD symptoms, including body weight, nutrition, alcohol consumption, smoking, the intake of non-steroidal anti-inflammatory drugs, and sleeping position. Several studies have found an increased risk of oesophagitis in overweight patients. Studies on the link between body mass index (BMI) and GERD symptoms have mixed results, although most data indicate an increased risk of symptoms in overweight and obese subjects. 
With regard to nutrition, many patients and physicians associate the occurrence of reflux symptoms with certain dietary factors (26.27). Accordingly, patients are often advised to avoid fatty meals, sweets, coffee and tea.
Being overweight or obese was found to be significantly associated with GERD symptoms. Further risk factors included the consumption of sweets or white bread at least once a day, drinking spirits several times a week, and being a current or former smoker. Physical exercise and the consumption of non acidic fruits seems to have had a protective effect (25).
* Lifestyle modifications include the following:
          o Losing weight (if overweight)
          o Avoiding alcohol, chocolate, citrus juice, and tomato-based products
          o Avoiding large meals
          o Waiting 3 hours after a meal before lying down
          o Elevating the head of the bed 8 inches
Saliva as a Modifying Factor
Buffering capacity of saliva refers to its ability to resist a change in pH when an acid is added to it.  This property is largely due to the bicarbonate content of the saliva which is in turn dependent on salivary flow rate. Bicarbonate concentration also regulates salivary pH.  Therefore, there is a relationship between salivary pH, buffering capacity and flow rate, with pH and buffer capacity increasing as flow rate increases (28).
Saliva is normally secreted continuously at about 500ml per day but can be stimulated by mastication. Chewing sugar free gum can increase the initial salivary flow rate by a factor of 10.(29). in addition to the more effective clearance of carbohydrate from the mouth, stimulated saliva contains higher concentrations of remineralising ions and bicarbonate to buffer the acids formed in plaque. Therefore, salivary function is an important factor in the aetiology of erosion.
The use of sugar free gum after eating meals and snacks, therefore, promotes the remineralisation of enamel lesions, and has been shown to reduce clinical caries development. It has also been shown that this stimulated saliva is more effective in its ability to buffer and remineralise.(30). Research has suggested that salivary stimulation from chewing sugar free gum after the consumption of sugary foods not only prevents the fall in pH normally seen, but also results in an increased remineralising effect in previously demineralised enamel. (31, 32).
Research has also shown that chewing sugar-free gum for half an hour after a meal can reduce acidic postprandial oesophageal reflux (33). The research showed that chewing gum could induce increased swallowing frequency, thus improving the clearance rate of reflux within the oesophagus.
Oral management of this condition includes regular examination, careful attention to oral hygiene and avoidance of abrasive toothpaste. Remineralisation can be encouraged by the use of sugar free gum and either fluoride or calcium phosphate paste. In terms of nutrition, decrease amount and frequency of acidic foods or drinks and to reduce GERD symptoms avoid smoking, alcohol and refined carbohydrates. Provision of mechanical protection could include application of composites and direct bonding where appropriate to protect exposed dentin and construction of an occlusal guard is recommended if a bruxism habit is present. To monitor stability, the use of casts or photos to document tooth wear status can be useful.
 The diagnosis of GERD needs to be made and confirmed by the medical profession, however, initial symptoms may present to the dental team as unexplained erosion particularly on the lingual and palatal surfaces. By being aware of erosion patterns and the symptoms of GERD we as a profession may be able to help manage the health of the GERD patient. 


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