The relationship between gastro-oesophageal reflux disease and dental erosion

Risk indicators for tooth wear in New Zealand school children

AIM

To investigate the prevalence and severity of tooth wear in the primary dentition of a representative sample of New Zealand school children and relate these to possible risk factors.

DESIGN

A cross-sectional study.

SETTING

Primary schools in Dunedin, New Zealand.

PARTICIPANTS

104 children of both sexes, aged between 5 and 8 years, randomly selected.

METHODS

Clinical examinations of the buccal, occlusal/incisal and lingual surfaces of deciduous canines and molars.

MAIN OUTCOME MEASURE

Degree of wear and the presence of dentinal cupping of teeth. Information on weaning and consumption of fruit-based drinks at bed time, frequency of consumption of fruits, yoghurt, pickled foods, fizzy and fruit-based drinks.

RESULTS

The prevalence of tooth wear was similar in boys and girls and there were no significant differences between sides of the arches. A high percentage (82%) of children had at least one primary tooth with dentine exposed. While maxillary canines showed the greatest prevalence of dentine exposed, maxillary molars displayed the greatest prevalence of cupping. Severe tooth wear was less prevalent among children weaned after 12 months (14.3%) than those weaned earlier (27.9% P < 0.01). There were no statistically significant associations between wear and the consumption of fruit, yoghurt, pickled foods, fizzy drinks or fruit-based drinks.

CONCLUSIONS

Tooth wear associated with dentine exposure is common in 5-8 year old children. This is not significantly associated with dietary factors, but appears to be related to early weaning from the breast.

The oral medicine of tooth wear

This review illustrates, through a series of case histories, how oral medicine insights aid the diagnosis and management of patients with excessive tooth wear. The cases reviewed are drawn from the records of 500 southeast Queensland patients referred to the author over a 12 year period. Patients most at risk of dental erosion have work and sports dehydration, caffeine addiction, gastro-oesophageal reflux, asthma, diabetes mellitus, hypertension or other systemic diseases or syndromes that predispose to xerostomia. Saliva protects the teeth from the extrinsic and intrinsic acids which cause dental erosion. Erosion, exacerbated by attrition and abrasion, is the main cause of tooth wear. These cases illustrate that teeth, oral mucosa, salivary glands, skin and eyes should be examined for evidence of salivary hypofunction and attendant medical conditions. Based on comprehensive oral medicine, dietary analyses and advice, it would seem patients need self-management plans to deal with incipient chronic tooth wear. The alternative is the expensive treatment of pain, occlusal damage and pulp death required to repair the effects of acute severe tooth wear.

Dental erosion in deciduous teeth--an in vivo and in vitro study

OBJECTIVE

The aims of this study were to report on severe dental erosion and its associated etiological factors in deciduous teeth of Saudi children (n=16, X macro=6.5 years, R=5--8) in vivo, and to confirm (or reject) the clinical diagnosis by scanning electron microscopy (SEM). Another aim was to study progression of erosion in vitro using extracted healthy deciduous and permanent teeth.

METHOD

For the in vivo study, a questionnaire and clinical examination was completed, medical history obtained and exfoliated eroded teeth (n=8) examined by SEM. For the in vitro study, enamel specimens were prepared from Saudi (n=21) and Finnish (n=19) deciduous teeth as well as Finnish permanent teeth (n=20), immersed in 2% citric acid for 5--30 min, microhardness measurements performed, and the specimens studied by SEM.

RESULTS

The in vivo investigation showed that high intake of acidic drinks and fruits, upper respiratory tract problems and frequent medications may constitute possible etiological and/or aggravating factors for severe dental erosion in Saudi children. Deciduous tooth enamel was softer than permanent tooth enamel. SEM showed no clear differences in the ultrastructure of the enamel specimens amongst the three groups. The clinical diagnosis of severe dental erosion in those cases studied was reliable as verified by SEM.

CONCLUSIONS

The presence of dental erosion in children is likely to be associated with a number of general health and dietary factors but is also aggravated by the relatively more rapid progression of erosion in the deciduous teeth.

Gastroesophageal reflux disease: New oral findings

OBJECTIVE

The objective of this study was to investigate the effects of gastroesophageal reflux disease (GERD) on dentition, salivary function, and oral mucosa.

STUDY DESIGN

Thirty-one patients with esophagitis underwent medical evaluation, which included taking their medical history, performing both an esophagogastroduodenoscopy and esophagus biopsy, and conducting a stomatologic examination. The latter consisted of an extraoral and intraoral physical examination, saliva tests (flow, buffer capacity, and pH), and biopsy and morphometry of the palatal mucosa, as well as taking a history of the patients' habits. Fourteen healthy volunteers from the same population were used as a control group.

RESULTS

No relationship between GERD and changes in the oral cavity was shown by saliva tests, oral clinical examination, or histopathologic examination of the palatal mucosa. However, morphometric analysis of the palatal epithelium showed a statistically significant difference between the patients with GERD and the control group.

CONCLUSIONS

GERD is associated with microscopic alterations in the palatal mucosa (epithelial atrophy and increased fibroblast number), which are only detected by morphometry.

Structured review of enamel erosion literature (1980-1998): a critical appraisal of experimental, clinical and review publications

OBJECTIVE

To attain an objective account of the methods to measure enamel erosion used in 1980-1998 publications, a structured review of the literature was undertaken.

METHODS

Inclusion and exclusion criteria were applied to 731 clinical/experimental research and review reports. Eighty-five included papers were subsequently rated according to 'hierarchy of evidence' guidelines to assess the strength of the report's design and the relevance of the evidence to replicating enamel erosion in vivo in humans. Scores were assigned to rate each aspect in the guidelines.

RESULTS

A total of 16 clinical, 13 review and 56 experimental papers were assessed; 36.4% were published during 1996-1998. Excluding reviews, 16 papers were qualitative and 56 quantitative; 51 used human enamel. Our classification yielded nine groups of methods (five scoring systems and 26 measurement techniques). CTFPHE (Can Med Assoc J 1992; 147: 443) grading of research reports indicated that 2.8% provided evidence grade I; 20.8%, grade IIa; 63.9%, grade III; and 12.5%, grade IV.

CONCLUSIONS

There has been a consistent increase in the body of knowledge. The overall quality of publications has not substantially changed over time. Experimental studies were more often quantitative, and quantitative studies had better research designs. No single group of research methods had obviously superior research designs.

Cola drinks consumption and oesophagitis

For oesophageal epithelial changes to develop from gastro-oesophageal reflux disease (GORD), the character of the refluxate must be acid enough to cause injury. Experimentally, copious perfusion of the oesophagus with weak acid is quite harmless. However, hydrochloric acid alone with a pH below 3.0 may cause oesophageal injury. Cola drinks are strongly acidic (pH 2.5). This study analyses the influence of and possible interaction between cola consumption and oesophagitis. Twenty rats were divided into two groups of 10. The animals received saline (pH 7.0) or cola (pH 2.6) per OS with 24 h free access to these solutions. After the experiment the oesophagus was dissected. The mucosa was macroscopically and histopathologically examined, and flow cytometric analysis was used to look for proliferative activity. The histopathological analysis showed that there is no difference between saline and cola. But the findings of cell cycle analysis showed that the effects of cola and saline in inducing oesophageal mucosal damage are different. In the cola group the values were G0/G1, 7.33 +/- 2.88; S, 29.88 +/- 2.88; G2/M, 0.10 +/- 0.01; PI (proliferative-regenerative index), 29.76 +/- 2.88. The rat cell population g0/g1 phases were found to be low (p < 0.01), and the cell population S and PI phases were found to be significantly elevated compared with the control group (p < 0.01). (G0/G1, 79.30 +/- 5.97; S, 16.06 +/- 8.27; G2/M, 4.66 +/- 4.03; PI, 20.03 +/- 6.01). These results were reflected in the proliferative index, which is used as a measure of the regeneration index. The data show that cola has proliferative and regenerative effects on the oesophageal mucosa, and it is possible that its regenerative effect is caused as a result of an irritant effect.

Erosion caused by gastroesophageal reflux: diagnostic considerations

Dental erosion occurs with a high prevalence in the general population, but its impact on prosthodontic care is often unrecognized. The etiology of dental erosion is difficult to establish because it may result from a variety of causes and may have different presentations. Our purpose was to review the literature relevant to dental erosion and to report a patient presentation in which an unusual pattern of severe erosion was the dental manifestation of asymptomatic gastroesophageal reflux disease.

Dental erosions and gastro-oesophageal reflux disease in institutionalized intellectually disabled individuals

OBJECTIVE

Both exogenous acids, from the diet, and endogenous acids, from stomach juice, can dissolve the enamel mineral, resulting in dental erosions. Gastric acid may reach the mouth by gastro-oesophageal reflux disease (GERD), recurrent vomiting, rumination and regurgitation. These conditions are frequently found in the intellectually disabled population. Therefore, we investigated the presence of dental erosions in combination with GERD among intellectually disabled inhabitants, with an IQ < 50, taken from three Dutch institutes.

MATERIALS AND METHODS

At random 63 individuals underwent an oesophageal pH test and dental screening and possible predisposing and attributable factors were determined. An abnormal pH level was defined as a pH < 4, > 4.5% of the measured time. Subjects with dental erosions were compared to those without dental erosions.

RESULTS

In 29 out of 63 (46.0%) cases evidence of dental erosions was found. In 19 of these 29 subjects with erosions (65.5%) GERD was diagnosed, compared to nine (26.5%) out of 34 subjects without erosions (P = 0.04). In the subjects with erosions mean duration of pH < 4 was 15.6% (range: 0.5-90.5) compared to 6.3% (range 0-40.4) in subjects without erosions (P = 0.02). An IQ < 35 was found to be predisposing (P < 0.001).

CONCLUSION

In this population of 63 institutionalised intellectually disabled persons dental erosions were diagnosed in 46%. Sixty-five per cent of them had GERD. Individuals with longer duration of pH < 4 than 6.3% of the measured time and with an IQ < 35 were at higher risk to develop dental erosions. This study shows that dental erosions in the intellectually disabled population might be an oral manifestation of GERD.

The prevalence, etiology and management of tooth wear in the United Kingdom

STATEMENT OF PROBLEM

Recent epidemiologic evidence suggests that tooth wear is now a significant problem in both children and adults. There is growing evidence that a major cause of severe wear in patients is regurgitation erosion due to a variety of factors including gastroesophageal reflux disease.

PURPOSE

The purpose of this article is to discuss the prevalence of tooth wear in the United Kingdom. Emphasis in management should be on accurate diagnosis, and in some patients, long-term monitoring before embarking on any irreversible, interventive treatment. Even when treatment is necessary, a period of monitoring is helpful to assess the rate of progress of the wear, the effectiveness of preventive measures, and therefore the extent of the treatment necessary.