The association between erosive toothwear and gastro-oesophageal reflux-related symptoms and disease: A systematic review and meta-analysis

Systematic review and meta-analysis on prevalence and anamnestic risk factors for erosive tooth wear in the primary dentition

BACKGROUND

Erosive tooth wear is a multifactorial and common condition in children.

AIM

This systematic review and meta-analysis aimed to determine the prevalence and key risk factors for erosive tooth wear in the primary dentition of children up to 7 years of age.

DESIGN

Electronic databases (PubMed, Embase, Scopus, and Web of Science) were searched in February 2023 for observational studies reporting prevalence and anamnestic risk factors. Additionally, a manual hand search was performed. Meta-analyses were conducted for the prevalence and odds ratios of identified risk factors. Risk of bias was assessed using the Newcastle-Ottawa scale modified for cross-sectional studies.

RESULTS

A total of 26 sources, reporting on 23 studies, were included in the systematic review. The overall estimated prevalence of children with erosive tooth wear in the primary dentition amounted to 35.6% (95% CI: 24.8-48.1). Anamnestic factors were structured into domains. Meta-analyses revealed gastroesophageal reflux disease (GERD; padj. = .008; OR = 1.98, 95% CI: 1.37-2.87), consumption of acidic food (padj. < .001; OR = 5.14, 95% CI: 3.56-7.42) and acidic drinks (padj. < .001; OR = 6.90, 95% CI: 4.64-10.25), holding beverages in the mouth while drinking (padj. = .035; OR = 1.82, 95% CI: 1.26-2.63), and snacking regularly (padj. = .041; OR = 1.58, 95% CI: 1.18-2.10) to be significantly associated with erosive tooth wear.

CONCLUSION

Future research should use standardized questionnaires to assess erosive tooth wear and its underlying risk factors (PROSPERO: CRD4202339776).

Prevalence of erosive tooth wear in risk group patients: systematic review

OBJECTIVE

This systematic review investigates the prevalence of erosive tooth wear (ETW) in individuals classified as risk groups (gastroesophageal reflux disease, eating disorders, special diets, acidic beverage, drugs and alcohol, legal drugs and medications, and occupational or sports).

MATERIALS AND METHODS

The research was conducted in nine databases (PubMed/MEDLINE, Embase, Cochrane Library, LILACS/BVS, SciELO, Scopus, Science Direct, Open Grey, and Web of Science) up to April 2024 (PROSPERO CRD42021270150), along with a manual search of grey literature. Observational studies involving children and adults from these previously mentioned risk groups, which provided data on ETW prevalence, were included without date or language restrictions. The methodological quality of studies was evaluated using the Joanna Briggs Institute's Prevalence Data Critical Appraisal Tool. General and subgroup data were meta-analyzed using a random-effects model.

RESULTS

Overall, 4403 studies were retrieved, out of which 148 met the inclusion criteria. Each risk group showed higher prevalences of ETW in these patients in general and subgroup analysis; although subgroup analysis was not possible for all risk groups due to the heterogeneity of the indices found.

CONCLUSIONS

The Legal drugs and Medications risk group showed lower overall prevalence values (30%), while the Drugs and Alcohol risk group obtained higher values (67%). Prevalence rates for other groups were: Gastroesophageal reflux disease (54.1%), Eating Disorders (65%), Special Diets (65.9%), Acidic Beverages (40%), Occupational and Sports (51%).

CLINICAL RELEVANCE

This systematic review highlights that risk groups are indeed at significant risk for the development of ETW and greater preventive care and dental monitoring are needed.

Factors associated with prevalence and severity of erosive tooth wear in patients with reflux oesophagitis

BACKGROUND

Extrinsic factors for erosive tooth wear (ETW) have been widely reported, but the intrinsic factors for wear remain unclear.

OBJECTIVES

The aim of this study was to evaluate the factors associated with the prevalence of ETW in patients with reflux oesophagitis (RO). To prevent severe ETW with RO, factors associated with severity of ETW were also evaluated.

METHODS

A total of 270 patients with RO were recruited. A modified tooth wear index was used to evaluate the prevalence and severity of ETW. Salivary secretion and buffering capacity were assessed prior to endoscopy. Subjects were asked to complete a medical condition and oral self-care questionnaire. Univariate and multivariate analyses were employed to identify factors collectively associated with the prevalence and severity of ETW.

RESULTS

A total of 212 cases were categorized as patients with ETW (148 with mild ETW and 64 with severe ETW). Multivariate analyses indicated that saliva secretion, severity of RO and proton pump inhibitor (PPI) resistance were associated with the prevalence of ETW, whereas age, BMI and severity of RO were associated with the severity of ETW. The odds ratio of saliva secretion and BMI were less than 1, meaning that higher saliva secretion resulted in a lower prevalence of ETW and lower BMI was associated with severe ETW.

CONCLUSION

Saliva secretion, severity of RO and PPI resistance were associated with the prevalence of ETW, whereas age, BMI and severity of RO were associated with the severity of ETW. Lower saliva secretion and BMI were significant factors for ETW.

Salivary Proteins in Human Acquired Enamel Pellicle (AEP) on Eroded and Uneroded Teeth in Patients with Gastro-Oesophageal Reflux Disease (GORD)

The aim of this in vivo study was to compare total protein present in the salivary films (F) and acquired enamel pellicle (AEP) on eroded and non-eroded surfaces in patients suffering from GORD symptoms with and without GORD diagnosis (GORD, No-GORD). Thirty-nine patients suffering from GORD symptoms and erosive tooth wear on lower first molars and an unaffected posterior occlusal surface in the same quadrant were recruited from Guy's hospital, London. Salivary film and AEP were collected from the eroded and uneroded occlusal surfaces, using 0.5% sodium dodecyl sulphate (SDS)-soaked filter papers. Total protein concentration was analysed using bicinchoninic acid assay (BCA). Statistical analysis was conducted using Shapiro-Wilk, ANOVA, and Tukey's tests (p < 0.05), comparing four GDS sample types and GORD vs. No-GORD groups. The level of significance was set as p < 0.05. Data were compared between eroded and uneroded surfaces in the same patient with GORD symptoms, as well as between those with or without a GORD diagnosis (GORD, No-GORD). The AEP total protein concentration from the eroded [2.17 (0.49) mg/mL] and uneroded surfaces [2.24 (0.66) mg/mL] of the GORD group were statistically significantly lower than those on eroded [3.27 (1.01) mg/mL] and uneroded [3.33 (1.57) mg/mL] surfaces in the No-GORD group (p = 0.007) (p = 0.008), respectively. No statistically significant differences were observed for film and AEP between eroded and uneroded surfaces (p > 0.05).

Anamnestic risk factors for erosive tooth wear: Systematic review, mapping, and meta-analysis

OBJECTIVES

Erosive tooth wear is a multifactorial condition. The aim of this systematic review and meta-analysis was to identify key risk factors for erosive tooth wear in permanent dentition.

STUDY SELECTION

Observational studies reporting anamnestic risk factors for erosive tooth wear. Methodological quality and risk of bias were assessed using the modified Newcastle-Ottawa scale for cross-sectional studies. Risk factors were visually presented in a heatmap, and where possible, random-effects meta-analyses were performed for the odds ratios (ORs) of risk factors.

SOURCES

Electronic databases (MEDLINE, Embase, Scopus, and Web of Science) and manual searches in February 2023. The protocol was registered in PROSPERO (CRD4202339776).

DATA

A total of 87 publications reporting on 71 studies were included in the systematic review. The studies examined a variety of anamnestic risk factors (n = 80) that were categorized into ten domains (socio-demographics, socio-economics, general health, oral diseases, medication, oral hygiene, food, beverages, dietary habits, and leisure-related risk factors). Meta-analyses revealed significant associations between erosive tooth wear and male gender (padj.<0.001; OR=1.30, 95 % CI: 1.16-1.44), regurgitation (padj.=0.033; OR=2.27, 95 % CI: 1.41-3.65), digestive disorders (padj.<0.001; OR=1.81, 95 % CI: 1.48-2.21), consumption of acidic foods (padj.=0.033; OR=2.40, 95 % CI: 1.44-4.00), seasoning sauces (padj.=0.003; OR=1.28, 95 % CI: 1.13-1.44), nutritional supplements (padj.=0.019; OR=1.73, 95 % CI: 1.28-2.35), and carbonated drinks (padj.=0.019; OR=1.43, 95 % CI: 1.17-1.75). Most included studies exhibited low bias risk.

CONCLUSIONS

Observational studies investigated a variety of anamnestic risk factors for erosive tooth wear. Future studies should employ validated questionnaires, particularly considering the most important risk factors.

CLINICAL SIGNIFICANCE

Erosive tooth wear is a prevalent condition. Clinicians should concentrate primarily on symptoms of gastroesophageal reflux disease and dietary factors when screening patients at risk for erosive tooth wear.

Association between salivary characteristics and tooth wear: A systematic review and meta-analysis

OBJECTIVE

Literature was systematically reviewed to identify salivary characteristics and their association with tooth wear.

DATA

A protocol was developed a priori (PROSPERO CRD42022338590). Established systematic review methods were used for screening, data extraction, and synthesis. Risk of bias and the certainty of evidence were assessed using the JBI tools and GRADE, respectively. Direct and indirect association between tooth wear and salivary components and characteristics were assessed.

SOURCES

MEDLINE, Embase, SCOPUS, Web of Science, CINAHL, and additional sources were searched.

STUDY SELECTION

Studies reporting salivary characteristics in patients with tooth wear or models thereof were included. Animal and in-vitro studies and case reports were excluded.

RESULTS

One-hundred eleven studies were included. Qualitative analyses showed a negative association between tooth wear and salivary pH and flow rate in many studies. The higher the study size the higher the chances that an association with pH and flow rate was found. Xerostomia, buffer capacity and salivary consistency/viscosity had also some degree of association with tooth wear in fewer studies. Associations with the 39 salivary components were scarcer. Random effects meta-analyses (7 studies) showed that pH levels in stimulated whole saliva were lower in patient with tooth wear compared to controls (-0.07 [-0.10 to -0.04]). However, there was not enough evidence to establish a quantitative association with flow rate. The general risk of bias was unclear and the certainty of evidence was low or very low. A large diversity of methodologies limited the inclusion of all studies in quantitative synthesis.

CONCLUSION

From all potential risk factors, stimulated whole saliva pH showed a negative association, both quantitatively and qualitatively with tooth wear, indicating potential usefulness of pH monitoring in these patients. Moreover, associations between flow rate and tooth wear were observed qualitatively. However, in both cases the risk of bias was mostly unclear, and the certainty of evidence was low. No causal associations could be observed.

CLINICAL SIGNIFICANCE

Tooth wear is a prevalent condition that may lead to functional or esthetic impairments and pain. Knowing the potential risk factors like salivary pH or flow rate and their dynamics could be relevant during tooth wear monitoring and to intervene accordingly, especially in conditions like gastroesophageal reflux disease.

Gastric acid challenge of lithium disilicate-reinforced glass-ceramics and zirconia-reinforced lithium silicate glass-ceramic after polishing and glazing-impact on surface properties

OBJECTIVES

To investigate the impact of simulated gastric acid on the surface properties of lithium disilicate-reinforced glass-ceramics and zirconia-reinforced lithium silicate glass-ceramic after certain polishing and glazing procedures.

MATERIALS AND METHODS

Four different types of square-shaped specimens (10 × 10 × 2 mm3, n = 13) were manufactured: lithium disilicate-reinforced glass-ceramic milled and polished (LDS-P); milled, polished, and glazed (LDS-PG); milled, glazed, and no polishing (LDS-G); and milled and polished zirconia-reinforced lithium silicate glass-ceramic (ZR-LS). Specimens were immersed in hydrochloride acid (HCl 0.06 M, pH 1.2) to simulate gastric acid irritation and stored in the acid for 96 h in 37 °C. Specimen weight, surface gloss, Vickers surface microhardness and surface roughness (Ra, Rq, with optical profilometer), and surface roughness on nanometer level (Sq, Sal, Sq/Sal, Sdr, Sds with atomic force microscope) were measured before and after the acid immersion.

RESULTS

ZR-LS specimens lost significantly more weight after acid immersion (p = 0.001), also surface microhardness of ZR-LS was significantly reduced (p = 0.001). LDS-G and LDS-PG showed significantly lower surface roughness (Sa, Sq) values compared to LDS-P before (p ≤ 0.99) and after (p ≤ 0.99) acid immersion and ZR-LS after acid immersion (p ≤ 0.99).

CONCLUSIONS

Gastric acid challenge affects the surface properties of lithium disilicate-reinforced glass-ceramic and zirconia-reinforced lithium silicate glass-ceramic. Glazing layer provides lower surface roughness, and the glazed surface tends to smoothen after the gastric acid challenge.

CLINICAL RELEVANCE

Surface finish of lithium disilicate-reinforced glass-ceramic and zirconia-reinforced lithium silicate glass-ceramic has a clear impact on material's surface properties. Gastric acidic challenge changes surface properties but glazing seems to function as a protective barrier. Nevertheless, also glazing tends to smoothen after heavy gastric acid challenge. Glazing can be highly recommended to all glass-ceramic restorations but especially in patients with gastroesophageal reflux disease (GERD) and eating disorders like bulimia nervosa.

The impact of gastrointestinal diseases on oral and maxillofacial surgery outcomes

OBJECTIVE

We analyzed the complication rates and outcomes in patients with gastrointestinal disorders who had undergone maxillofacial surgery.

STUDY DESIGN

We retrospectively analyzed 289 patients with inflammatory bowel disease (IBD), 142 with gastroesophageal reflux disease (GERD), and 42 with celiac disease (452 total) who had undergone oral and/or maxillofacial surgery. We examined their characteristics, medications they had taken, surgeries they had undergone, and complications they had experienced. Based on the results of univariate analysis, we selected variables for multivariable logistic regression to identify independent predictors of postoperative complications.

RESULTS

We found a complication rate of 10% in patients with IBD, 6.9% in patients with GERD, and 9.5% in patients with celiac disease. Dentoalveolar treatment was significantly associated with an increased risk of postoperative complications in patients with IBD and GERD.

CONCLUSIONS

Oral and/or maxillofacial surgery is safe in most patients with IBD, GERD, and celiac disease. Preventive measures for postoperative complications should be considered in patients with IBD and GERD undergoing dentoalveolar treatment.

Risk factors of tooth wear in permanent dentition: A scoping review

BACKGROUND

Tooth wear (TW) prevalence is high and increasing and has important consequences on the patient's quality of life. Knowledge of risk factors is crucial to promote diagnosis, prevention strategies and timely interceptive treatment. Many studies have identified TW risk factors.

OBJECTIVE

This scoping review aims to map and describe suspected available factors associated with TW in permanent dentition based on quantitative measurement.

METHODS

The scoping review was conducted using the PRISMA extension of the Scoping Reviews checklist. The search was conducted in October 2022 from the Medline® (PubMed® interface) and Scopus® databases. Two independent reviewers selected and characterised the studies.

RESULTS

2702 articles were identified for assessment of titles and abstracts, and 273 articles were included in the review. The results show a need to standardise TW measurement indices and the study design. The included studies highlighted various factors, classified into nine domains: sociodemographic factors, medical history, drinking habits, eating habits, oral hygiene habits, dental factors, bruxism and temporomandibular disorders, behavioural factors, and stress. Results related to chemical TW (erosion) risk factors underline the importance of eating disorders, gastroesophageal reflux and lifestyle, particularly drinking and eating behaviours, which supports developing public health information campaigns and interventions. Besides chemical, this review identifies evidence of several mechanical TW risk factors, such as toothbrushing and bruxism; the influence of this last factor needs to be further explored.

CONCLUSIONS

TW management and prevention require a multidisciplinary approach. Dentists are in the first line to detect associated diseases such as reflux or eating disorders. Consequently, practitioners' information and guideline diffusion should be promoted, and a TW risk factors checklist (the ToWeR checklist) is proposed to help diagnostic approaches.

Prevalence and association of gastroesophageal reflux and dental erosion: An overview of reviews

OBJECTIVES

The aim of this overview of reviews was to retrieve and evaluate the available evidence concerning the prevalence and association between gastroesophageal reflux disease (GERD) and erosive tooth wear (ETW).

DATA

A literature search was conducted in electronic databases and relative systematic reviews with or without meta-analyses were located. Updated supplemental search was also undertaken to identify additional primary studies.

SOURCES

Medline (via Pubmed), Embase, Scopus, Cochrane Register of Systematic Reviews, PROSPERO and Epistemonikos.org database were searched. Additional search of the grey literature, abstracts of conferences and meetings as well as manual search of the reference lists of retrieved studies, was also performed.

STUDY SELECTION

The search retrieved 116 systematic reviews of which 10 were considered eligible and eight additional primary studies.

CONCLUSIONS

GERD constitutes a risk factor for ETW and there is a positive association between the two conditions. In the present overview, despite the heterogeneity between studies and the low level of evidence, it was clearly supported that individuals with GERD have an increased probability of also presenting with signs of ETW. In special groups of population, a high association was found between GERD and ETW. The geographic location may affect the association between GERD and ETW, while regarding the effect of flow rate, buffering capacity of saliva and oral microbial changes caused by GERD, the results were controversial.

CLINICAL SIGNIFICANCE

Appropriate preventive dental care should be considered for individuals with GERD and a multidisciplinary medical and dental approach for the management of individuals with ETW is advised. The results of this study can be used by dentists dealing with typical and atypical GERD signs and symptoms in the oral environment, but also by the physicians and gastroenterologists who need to motivate their patients for oral examination.

The association between erosive toothwear and asthma - is it significant? A meta-analysis

BACKGROUND

The association of asthma with oral conditions such as dental caries, dental erosion, periodontal diseases and oral mucosal changes has been the subject of debate among dental practitioners. Existing evidence indicates that an inhaler is the most common and effective way of delivering the asthma medications directly into the lungs. Few studies in the past attributed this association to the changes in salivary flow caused due to these medications. Considering this unclear association, the aim of the present meta-analyses is to identify the association between erosive toothwear and asthma from individual studies conducted until date.

METHODOLOGY

Electronic databases were systematically searched until 30th September 2022. Articles identified using the search strategy were imported to RAYYAN systematic review software. Data was extracted relating to study design, geographic location, year of publication, sample size, the assessment method for erosive toothwear and asthma. The Newcastle Ottawa scale was utilized to assess the quality of evidence reported from the included studies. RevMan Version 5.3 was used to perform a random-effects meta-analysis to produce pooled estimates from OR and 95% CI of included studies. The I² statistic was used to determine the extent of heterogeneity. A funnel plot was generated to visually assess the potential for publication bias. Sensitivity analyses were performed by excluding individual studies one at a time. GRADE approach was used for grading the evidence for key comparisons.

RESULTS

Twelve articles were included in the final meta-analysis. A total of 1027 asthmatics and 5617 non-asthmatics were included. All studies demonstrated moderate to low risk of bias. The overall pooled estimate (OR: 2.03; 95% CI: 0.96, 4.29) and subgroup analyses in children (OR: 1.67; 95% CI: 0.63, 4.42) did not show statistically significant difference in the occurrence of dental erosion between the asthmatic and non-asthmatic group. However, asthmatic adults had significantly greater dental erosion in comparison to the control adults (OR: 2.76; 95% CI: 1.24, 6.16). Sensitivity analyses also provided inconclusive evidence. Funnel plot asymmetry indicated significant heterogeneity, changes in effect size and selective publication.

CONCLUSION

The association between inhalational asthmatic medication and tooth wear is inconclusive. There are a number of confounding factors that play a greater role in causing dental erosion in these patients. Dentist must pay particular attention to these factors while treating asthmatic patients. The authors produce a comprehensive checklist in order to ensure complete assessment before providing advice on their medications alone.

Clinical factors to consider in definitive treatment planning for patients with tooth wear

Diagnosis, disease control and prevention are the precursors to successful definitive restorative treatment of pathological tooth wear. This case series illustrates how proposed key clinical features can influence treatment complexity and provide the clinician with a logical sequence of treatment options for definitive management of tooth wear.

Tooth wear and socioeconomic status in childhood and adulthood: Findings from a systematic review and meta-analysis of observational studies

OBJECTIVES

To evaluate the association and level of evidence between socioeconomic status (SES) and tooth wear (TW) in children, adolescents, and adults.

DATA

Eligibility criteria comprised population-based observational studies assessing the association between SES and TW in permanent dentition of adolescents and adults. Interventional and descriptive studies or those without an internal comparison between exposed and nonexposed groups were excluded. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were applied where applicable. Risk of bias (RoB) was assessed using the Newcastle-Ottawa scale. Meta-analyses were conducted to estimate the pooled effect measures. Q-statistic, I²statistic, subgroup and sensitivity analyses assessed study heterogeneity.

SOURCES

PubMed/Medline, Embase, Scopus, Web of Science, LILACS, SciELO, Cochrane Library, and Google Scholar databases were searched for articles published in English between 1st January 1980 and 31st March 2021.

RESULTS

Sixty-five studies were included, involving 63,893 participants in over 30 countries. A positive association was found between TW and education (OR=1.25 [0.96; 1.62]), family income (OR=1.18 [0.91; 1.53]), and private school (OR= 1.24 [0.90; 1.72]) among adolescents. Higher educated adults had a lower risk for TW (OR=0.70 [0.52; 0.93]). Most included studies had a moderate RoB. Limitations relating to population representation and assessment methodologies were identified in the included studies.

CONCLUSIONS

SES was associated with TW with its direction depending on the individuals' age. The overall quality of evidence was moderate.

CLINICAL SIGNIFICANC

SES should be included as part of the routine screening and risk assessment for tooth wear.

Oral Manifestations of Rett Syndrome-A Systematic Review

Rett Syndrome is an x linked developmental disorder which becomes apparent in females after 6 to 18 months of age. It leads to severe impairments including loss of speech, loss of hand movements/manual dexterity, characteristic hand movements such as hang wringing and intellectual disability/learning problems. This systematic review was carried out to identify the dental manifestation of Rett syndrome and to shed light on treatment options available for oral health problems associated with Rett syndrome. A systematic literature search was conducted on the PubMed, Scopus, Biomed, Web of Science, Embase, Google Scholars, Cochrane and CINAHL using the following entries: Rett syndrome (n = 3790), Oral health and Rett syndrome (n = 17), dental health of Rett syndrome patients (n = 13), and the MeSH terms listed below: Rett syndrome and Oral Health (n = 17), Rett syndrome and dentistry (n = 29). The final review included 22 search articles. The most common oral findings was bruxism. Masseteric hypertrophy was also reported. Anterior open bite and non-physiological tooth wear was observed. Other oral manifestations of Rett syndrome included mouth breathing, tongue thrusting, digit/thumb sucking, high arch palate. Increased awareness and dental education amongst dentists and assistants regarding the dental manifestations of Rett syndrome and similar neurodevelopmental disorders is required to improve the level of care and empathy they can provide to these differently able patients. Research on dental aspects of Rett is scarce and this remains a neglected topic.