Incidence and Pattern of Dental Erosion in Gastroesophageal Reflux Disease Patients.

AIM: Gastroesophageal reflux disease (GERD) is a very common condition whose consequences of are localized not only in the esophagus; extra-esophageal involvement has frequently been reported. The aim of the study is to examine the incidence and pattern of dental erosion in GERD patients.
METHODOLOGY: A total of 50 patients were recruited in this study (control -25 and GERD -25). All participants diagnosed having GERD by the endoscopic examination by their gastroenterologist are included. The patients were examined for dental erosion and will be quantified using Basic erosive wear examination index.
RESULTS: The results showed that the incidence of dental erosion was 88% as compared to 32% in the control group which was found to be statistically significant.

INTRODUCTION

Dental erosion is defined as the loss of tooth structure through a physicochemical process of dissolution of hard dental tissue due to acid exposure in the oral cavity, without bacterial activity. The etiology of dental erosion is multifactorial. The causes may consist of extrinsic acids or intrinsic factors.[1] The extrinsic factors include acidic foods, acidic beverages, sports drinks, and chewable Vitamin C tablets. Intrinsic factors are reported to be: regurgitation, recurrent stress-induced vomiting, certain psychosomatic disorders such as anorexia, bulimia, and rumination, and alcohol abuse,[2] the most common being gastroesophageal reflux disease (GERD) with regurgitation of gastric acid into the oral cavity.

The mechanism of erosion begins as superficial demineralization of the enamel, which can cause dissolution of the subsurface layers and eventual loss of tooth structure. Any acid with a pH below the critical pH of dental enamel (5.5) can dissolve the hydroxyapatite crystals in enamel.[3] The damaged dental surface is exposed to mechanical friction in connection with chewing, swallowing, or brushing, sometimes which may extend up to dentin/pulp.[4] Erosion from gastric acids forms smooth lesions which typically appear as cupped occlusal/incisal and concave buccal/facial surfaces.[5]

GERD is defined as involuntary muscle relaxing of the lower esophageal sphincter (LES), which allows refluxed acid to move upward through the esophagus into the oral cavity.[6] The acid produced in the stomach is used to digest food. Normally during food swallowing, the LES opens and allows the food and saliva to flow into the stomach and then it closes to its original position. However, in GERD, the sphincter does not close properly allowing the acid along with food to flow upward. The acid flowing up into the esophagus irritates and inflames the lining of the esophagus. The lining of esophageal is not strong as that of stomach to withstand the corrosive effects of acid; hence, a burning sensation is usually felt which may lead to complications as reflux esophagitis, hemorrhage, stricture, Barrett's esophagus, and adenocarcinoma.[7]

Extraesophageal manifestations possibly resulting from GERD include laryngeal, pharyngeal, respiratory, sinus, middle ear, and oral conditions. The effect of GERD on oral cavity can be extensive. Gastric acid usually reaches the oral cavity through the esophagus. Tooth erosion and sensitivity, sour taste, halitosis, and mucositis occur as extraesophageal manifestation of GERD in oral cavity.[8]

Numerous studies have been reported in the literature to understand the relationship between dental erosion and GERD. Based on clinical experience, the patients suffering from GERD are invariably prone to dental erosion. In many cases, dentists have been the first to diagnose GERD due to the presence of dental erosion. Thus, dentists play an important role in patients with GERD. In this paper, we propose to examine the evidence along with the pattern of dental erosion in GERD.

The aim of the present study is conducted to investigate and evaluate the incidence and pattern of dental erosion in patients with GERD. The study also aims to discuss the dental implications of GERD and to create awareness among the patients about the oral health issues arising as a consequence of GERD.

MATERIALS AND METHODS

A cross-sectional descriptive study employing simple random sampling was conducted among out patients reporting to the Department of Conservative Dentistry, Chettinad Dental Hospital and Department of Gastroenterology, Chettinad Super Speciality Hospital. Sample size for the present study was estimated to be n = 50 based on the prevalence of dental erosion among patients with GERD, Farahmand et al.(2013).[7] Patient aged between 18 and 40 years of both the genders who are diagnosed with GERD are included in the experimental group. The control group companies age-matched study participants without GERD.

Before the start of the study, ethical approval was obtained from the institution's ethics committee, Chettinad Academic and Research Institute. A written informed consent was obtained from the study participants.

The survey instrument comprises demographic data and clinical examination for assessment of the dental erosion using the Basic Erosive Wear Examination Index Alina P[1] for the study.

Before the clinical examination, the examiner was trained to record the Basic Erosive Wear Examination Index in the Department of Conservative Dentistry. A single examiner conducted clinical examination of the study participants under proper illumination. The intraexaminer reliability was α = 0.86 (kappa statistics).

Dental erosion assessment

Dental erosion was assessed by clinical examination using a mouth mirror and straight probe. The severity of the erosion is quantified using the Basic Erosive Wear Examination Index Alina P[1] as follows.

Assessment scale

Degree 0 is characterized in the area B/L/O/I/C (B – Buccal, L – Lingual, O – Occlusal, I – Incisal, C – Cervical) to be without loss of surface characteristics, without loss of contour. Degree 1 in the same area is characterized as loss of surface characteristics and slight loss of contour. Degree 2 in the same area is characterized as loss of enamel with exposed dentin surfaces <1/3 of the surface, loss of enamel with dentin exposure, and defect with depth <1 mm. Degree 3 in the same area is characterized as loss of enamel with exposed dentin surface >1/3 of surface, loss of enamel with no major loss of dentin, secondary dentin or dental pulp exposure, and defect with depth of 1–2 mm. Degree 4 in the same area is characterized as complete loss of enamel with exposure of secondary dentin or pulp chamber, secondary dentin or dental pulp exposure, and defect with depth >2 mm with secondary dentine.

The collected data were analyzed using SPSS statistical software (SPSS Inc., version 16, Chicago, IL, USA). Chi-square test was applied and the results were considered to be statistically significant if P < 0.05.

RESULTS

A cross-sectional study was conducted to assess the incidence and pattern of dental erosion among GERD patients and non-GERD patients (control). The results demonstrate that the prevalence of dental erosion is high among patients with GERD than control patients, and the results are statistically significant (P < 0.05) [Figures 1 and 2]. Furthermore, Degree 1 type of dental erosion is more common in both the groups of patients, and there is no significant difference in the pattern of erosion among the study population (P < 0.05). There was no Degree 4 type of dental erosion in both GERD and control group [Table 1].

Figure 1

Comparison of erosion between patients with gastroesophageal reflux disease and controls

Figure 2

Distribution of dental erosion pattern among patients with gastroesophageal reflux disease and controls

Table 1

The distribution of study participants according to the disease and gender

DISCUSSION

GERD has become a widespread and frequent complaint among the general public in the present decade with the prevalence of 10%–20%.[1] This is defined as the condition where mucosal damage due to upward movement of gastric acid from stomach to esophagus is seen.

GERD causes dental erosion in higher frequency. Dental erosion is defined as the loss of tooth structure through a physicochemical process of dissolution of hard dental tissue in connection with environmental acidification in the oral cavity, without bacterial activity.[1] The factors that increase the incidence of dental erosion are also the factors that increase risk of GERD.

Several studies have suggested that patients with GERD are prone more to dental caries that normal population.[89]

Numerous studies have been conducted to show the association of GERD with dental erosion. However, there is a shortage of studies which examined the incidence of dental erosion in Indian population. Thus, this study was undertaken to examine the incidence of dental erosion in GERD patients in India.

The patients with chronic medical disease such as blood pressure, diabetics, and those with habits of regular consumption of soft drinks and sour foods are excluded through a questionnaire. These patients were excluded so that data regarding only dental erosion due to GERD can be collected and the erosion due to other factors can be eliminated from the study. The common methods for the diagnosis of GERD include the assessment of gastric symptoms, a proton-pump inhibitor drug test, esophageal pH monitoring, and upper endoscopy.

In the present study, patients diagnosed with GERD using upper GI endoscopy were included as upper GI endoscopy is considered the gold standard for confirming GERD. Dental erosion can be quantified using numerous indices such as erosion grading scale of Ganss and others,[7] erosion grading scale of Eccles and Jenkins,[7] and Aine erosion index.[10]

The patients in the present study were clinically examined for dental erosion and scores were tabulated using the Basic Erosive Wear Examination Index by Alina P et al.[1] This index was chosen as it is a simple and comprehensive. The data were then subjected to statistical analyses using SPSS statistical software (SPSS Inc., version 16, Chicago, IL, USA) and results were obtained.

The results showed that the incidence of dental erosion was 88% as compared to 32% in the control group which was found to be statistically significant. Similar results were obtained by Farahmand et al.[7] and Alavi G et al.[2] There were no significant differences in the pattern of erosion among the two groups.

Farahmand et al.,[5] 2013, evaluated recurrent exposure to gastric acid in GERD contributing to tooth erosion. The results showed that 59 (98.1%) of GERD group had dental erosion while 11 (19.0%) of control group had the erosion (P < 0.0001).

Alavi G et al.,[2] 2014, investigated the association of GERD with dental erosion in a sample of Iranian population regarding the standing difference in the Iranian oral hygiene and diet. The prevalence of dental erosion in GERD patients (22.6%) was found to be higher than the suspected (5.3%) and the healthy (7%) individuals.

In this study, distribution of dental erosion pattern among patients with GERD and controls, Degree 1 type of dental erosion is more common in both the group of patients, and there is no significant difference in the pattern of erosion among the study population (P > 0.05) [Tables 2 and 3]. There was no Degree 4 type of dental erosion in both GERD and control group. Similar results were obtained by Farahmand et al.[7]

Table 2

Comparison of erosion between patients with gastroesophageal reflux disease and controls

Table 3

The distribution of dental erosion pattern among patients with gastroesophageal reflux disease and controls

Farahmand et al.,[7] 2013, evaluated erosion grade out of which 34 (64.2%) of GERD group and 8 (72.7%) of control group showed Grade 1 dental erosion (P = 0.880). The most common pattern of dental erosion was generalized form in both groups.

The ever-increasing cases of GERD in the present age are posing a significant health issue. The concomitant increase is of considerable importance to the dental health-care professional. There is a higher incidence of tooth sensitivity, erosive facets, loss of mineralized tissue, dished-out deformities, and sharp margins of the teeth and can be severe enough to involve the entire dentition and also eventually causing pulpal/periapical pathology. The loss of tooth structure can also cause occlusal discrepancies such as loss of vertical dimension, all of which cause extreme difficulty in mastication which is more commonly seen in geriatric patients. Tooth surface loss around existing restorations can cause gaps leading to microleakage and secondary caries. Thus, it can be seen that the consequences of dental erosion can be widespread and momentous.

Often, it is seen that the dentist is the one diagnosing cases of dental erosion initially which can then lead to a subsequent diagnosis of underlying condition such as GERD. Thus, a close cooperation of the dentist with the patients’ physician/gastroenterologist is necessary for the comprehensive management of the condition. It is also imperative that the patients are educated and made aware of the effects of GERD on dental tissues so that timely treatment can be delivered. Furthermore, the dental professionals must be diligent and conscientious to diagnose dental erosion in its early stages and refer to the physician if cases of GERD are suspected. This will allow early intervention and prevention of any further disastrous consequences of tooth surface loss.

CONCLUSION

The results of this study prove that incidence of dental erosion in GERD patients is higher than in normal patients. The clinical implication of the study is that all patients diagnosed with GERD must be evaluated for dental erosion and proper awareness must be generated in such patients about the deleterious effects of GERD on dental tissues. Further studies with a larger sample size are needed to analyze the incidence and prevalence of dental erosion in the population with GERD.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.