Gastro-oesophageal reflux is common in oligosymptomatic patients with dental erosion: A pH-impedance and endoscopic study

Atomic force microscopy analysis of the surface alterations of enamel, dentin, composite and ceramic materials exposed to low oral pH in GERD

Dental erosion is a significant topic in medical literature, both for gastroenterology and dental medicine. Dental structure loss has a psychosocial and functional significance. The pathogenesis of dental erosion in patients diagnosed with gastroesophageal reflux disease (GERD) characterized by the presence of an acidic oral environment after reflux episodes, is not well understood. The present study was designed to observe the effect of low oral pH in time on natural surfaces including enamel and dentine, but also on materials used in treating these dental destructions such as composites and ceramics. The acidic oral environment was estimated in relation to salivary pH. In the dental laboratory, 5-mm2 and 1-mm composite pieces of thick enamel, dentine, Emax Ceramic and Nexco Ivoclar were cut in order to be analyzed using atomic force microscopy (AFM) and to observe the surface alterations. Gastric acid was collected and mixed with saliva until a pH value of 6.0 was obtained, in which the pieces were immersed for 24, 120, 240 h. Roughness of each surface was calculated at a microstructure and nanostructure level. The results showed significant alterations in enamel and dentine exposed to a lower pH level beginning even at a short immersion time, in comparison with composites and ceramics which had no alterations. In conclusion, multidisciplinary attention should be given to detect and manage acidity of the oral cavity caused by GERD, in order to prevent dental erosion.

Contemporary diagnosis and management of dental erosion

OBJECTIVE

This article is aimed at providing an overview of the topic of erosive tooth wear (ETW), highlighting the clinical signs, diagnosis, and management of dental erosion.

OVERVIEW

With the increased prevalence of ETW, it is important that oral health professionals are able to recognize the early signs. Early clinical signs of dental erosion are characterized by loss of enamel texture, a silky glossy appearance, and sometimes a dulling of the surface gloss, referred to as the "whipped clay effect, cupping, and restorations 'standing proud'." The progression of ETW should be monitored by means of diagnostic models or clinical photographs. ETW can be as a result of acid attack of extrinsic or intrinsic origin.

CONCLUSION

There is an increase of ETW that is being recognized by the profession. The first step in diagnosing and management is to recognize as early as possible that the process is occurring. At that point a determination of whether the primary etiology is either intrinsic or extrinsic should be made. If these findings are confirmed, appropriate prevention, and management strategies can be adopted followed by appropriate restorative therapy.

CLINICAL SIGNIFICANCE

The prevalence of ETW continues to increase. It is therefore important that oral health care providers have a better understanding of the etiology, pathophysiology, and management of this condition. This review aims to provide the guidelines for diagnosis and management of dental erosion.

Individuals With Gastroesophageal Reflux Disease or Symptoms May Have Increased Odds of Erosive Tooth Wear

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION

The association between erosive toothwear and gastro-oesophageal reflux-related symptoms and disease: A systematic review and meta-analysis. Jordão HWT, Coleman HG, Kunzmann AT, McKenna G. J Dent 2020. https://doi.org/10.1016/j.jdent.2020.103284.

SOURCE OF FUNDING

None. The authors declared no conflict of interest.

TYPE OF STUDY/DESIGN

Systematic review with meta-analysis.

Nanoscale effects of beverages on enamel surface of human teeth: An atomic force microscopy study

Dental erosion has become a prevalence disease and attracted increasing attention worldwide. In this research, we quantitatively evaluate the mechanical and morphological changes in the very early stages of softening and weakening of human enamel surfaces induced by soft drinks using atomic force microscopy (AFM). With an increase of the immersion time in soft drinks, we found a significant increase of surface roughness (R_q) of the enamel surface. The prismatic structure of enamel was clearly observed after a 1-h immersion in Coca-Cola®, which shows its strong erosion effect. According to the elastic modulus mapping images obtained by AFM, a considerable decrease of elastic modulus (E) of enamel surface has been found as the enamel surface structures are etched away by soft drinks. A high surface roughness of enamel will result in a high chance of cavities due to easier bacterial adhesion on rougher surface, while a drastic deterioration of the mechanical properties of the enamel will weaken its protection property. Our findings show the serious influence of acidic drinks on enamel surface at the very beginning stage of etching process, which is quite meaningful for people to prevent dental erosion and keep dental health.

Laryngopharyngeal reflux, gastroesophageal reflux and dental disorders: A systematic review

OBJECTIVES

To investigate the role of gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) in the development of dental disorders.

METHODS

The first outcome was review of the role of reflux in the development of dental disorders in adults. The second outcome was review of the potential pathophysiological mechanisms underlying the association between reflux and dental disorders. Three investigators screened publications for eligibility and exclusion based on predetermined criteria through a literature search conducted on PubMed, Cochrane Library, and Scopus according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

RESULTS

From 386 publications, 24 studies were kept for analysis. Objective approaches were used in 16 studies to confirm GERD diagnosis. Pharyngeal reflux episodes (LPR) were considered in 2 studies. No study considered nonacid reflux. The study results supported a higher prevalence of dental erosion and caries in reflux patients compared with healthy individuals. Patients with dental erosion have a higher prevalence of reflux than controls. The pathophysiological mechanisms would involve changes in the saliva physiology. No study investigated the microbiota modifications related to reflux although the findings are supporting the critical role of microbiota change in the development of dental disorders. There is an important heterogeneity between studies about diagnostic methods and clinical outcome evaluation.

CONCLUSION

The involvement of reflux in the development of dental disorders is not formally demonstrated and requires future investigations considering pharyngeal acid and nonacid reflux episodes and in particular their potential impact on oral microbiota.

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

OBJECTIVES

To conduct a systematic review and meta-analysis to explore the association between erosive toothwear and gastro-oesophageal reflux disease or symptoms (GERD/S).

SOURCES

Electronic searches were performed in Scopus, Embase, and Web of Science databases for the identification of relevant studies, from 1980 until 2nd August 2019.

STUDY SELECTION

The review protocol was registered on PROSPERO (CRD42018096959) and the review was conducted according to PRISMA guidelines. Observational studies which examined the association between erosive toothwear, and GERD/S were included and categorised according to the use of objective or subjective measures of GERD/S. Where possible, odds ratios (OR) and 95 % confidence intervals (CI) were derived and pooled in a meta-analysis.

DATA

27 studies were considered relevant for the qualitative synthesis and 19 studies were pooled. Significantly increased odds of erosive toothwear were observed in individuals with GERD/S. This trend was more strongly associated with objectively measured GERD/S (OR 4.13, 95 % CI 1.68-10.13), compared to subjectively measured GERD/S (OR 2.69, 95 % CI 1.13-6.38). Whilst heterogeneity was very high these trends remained in most sensitivity and subgroup analyses conducted.

CONCLUSION

Individuals with GERD/S have a 2-4 fold increased odds ratio of also presenting with evidence of erosive toothwear compared with individuals who do not have GERD/S.

CLINICAL SIGNIFICANCE

This review suggests the need for a multidisciplinary medical and dental approach to managing individuals who present with erosive toothwear or GERD/S. Timely referrals between oral health services and gastroenterology should be considered as part of effective diagnosis and management.

Updates in the field of non-esophageal gastroesophageal reflux disorder

Introduction: Gastroesophageal reflux disease (GERD) is one of the most prevalent conditions in Western Countries, normally presenting with heartburn and regurgitation. Extra-esophageal (EE) GERD manifestations, such as asthma, laryngitis, chronic cough and dental erosion, represent the most challenging aspects from diagnostic and therapeutic points of view because of their multifactorial pathogenesis and low response to proton pump inhibitors (PPIs). In fact, in the case of EE, other causes must by preventively excluded, but instrumental methods, such as upper gastrointestinal endoscopy and laryngoscopy, have low specificity and sensitivity as diagnostic tools. In the absence of alarm signs and symptoms, empirical therapy with a double-dose of PPIs is recommended as a first diagnostic approach. Subsequently, impedance-pH monitoring could help to define whether the symptoms are GERD-related. Areas covered: This article reviews the current literature regarding established and proposed EE-GERD, reporting on all available options for its correct diagnosis and therapeutic management. Expert opinion: MII-pH could help to identify a hidden GERD that causes EE. Unfortunately, standard MII-pH analysis results are often unable to define this association. New parameters such as the mean nocturnal baseline impedance and post-reflux swallow-induced peristaltic wave index may have an improved diagnostic yield, but prospective studies using impedance-pH are needed.

Prevalence of non-carious cervical lesions among the general population of the Republic of Srpska, Bosnia and Herzegovina

INTRODUCTION

As non-carious cervical lesions (NCCLs) may compromise aesthetics and function, knowledge of their aetiological covariables enhances management of clinical complaints and success of restorative treatments.

AIMS

The primary aim of this study was to assess the presence of NCCLs among the general population of the Republic of Srpska, Bosnia and Herzegovina and the potential association with patient-related risk factors.

METHODS

A prevalence study of NCCLs included 738 respondents from eight towns/municipalities. Two dental practitioners examined all respondents. NCCLs were diagnosed according to the Smith and Knight tooth wear index, measured using a Williams periodontal probe. Data regarding risk factors were obtained through a structured questionnaire. Multivariate logistic regression was used to analyse the association of risk factors and the occurrence of NCCLs.

RESULTS

Non-carious cervical lesions were diagnosed in 384 (52%) respondents. Multivariate regression analysis showed that several variables were independently associated with the risk of developing NCCLs, including frequent consumption of acid food (P = 0.001), frequent consumption of acid drinks (P = 0.001), retaining drink in the mouth (P = 0.001), alcohol consumption (P = 0.030), bruxism (P = 0.018) and gastro-oesophageal reflux (P = 0.023). First mandibular premolars were the most affected teeth (left: 46.0%; right: 44.0%), followed by the second right maxillary premolars (37.3%), second left maxillary premolars (33.6%) and finally by the first right maxillary premolars (34.0%).

CONCLUSION

The results of the current study suggest that NCCLs occur frequently and have a multifactorial aetiology. The lowest prevalence was recorded among individuals younger than 20 years of age. As the majority of risk factors are modifiable, regular dental care could lead to the early detection of NCCLs.

Prevention of erosive tooth wear: targeting nutritional and patient-related risks factors

This article provides an overview of the nutritional and patient-related risk factors involved in the aetiology of erosive tooth wear (ETW) and the preventive strategies to counteract them. The first step is to diagnose clinical signs of ETW and to recognise causal factors. Low pH and high buffer capacity of foods/drinks are the major risk factors, while the calcium concentration is the main protective factor. Reduction of frequency of consumption and contact time of erosive foods/drinks with the teeth, use of straws appropriately positioned and consumption of dairy products are advisable. Oral hygiene has a role in the development of ETW, however, postponing toothbrushing is not clinically advisable. In cases of drug abuse, chronic alcoholism, GERD or bulimia, the patient must be referred to a doctor. Immediately after vomiting, patients might be advised to rinse the mouth. Saliva has an important protective role and patients with reduced salivary flow can benefit from the use of chewing gum. Recent studies have focused on improving the protective capacity of the acquired pellicle as well as on the role of protease inhibitors on dentine erosion. However, the degree of evidence for these preventive measures is low. Clinical trials are necessary before these measures can be recommended.

Dental erosion, prevalence and risk factors among a group of adolescents in Stockholm County

Aims

To investigate the prevalence and risk factors of dental erosion (DE) among a group of adolescents in Stockholm County.

Materials and methods

This cross sectional cohort study was conducted at three clinics of the Public Dental Service in Stockholm County. Fifteen and 17 year old adolescents (1335) who scheduled their regular dental health examination were asked to participate. After drop-outs a sample of 1071 individuals, 547 males and 524 females were enrolled in the study. Presence of erosive wear was diagnosed (yes/no) on marker teeth by trained dentists/dental hygienists and photographs were taken. The adolescents answered a questionnaire regarding oral symptoms, dietary and behavioural factors. Two calibrated specialist dentists performed evaluation of the photographs for severity of DE using a modified version of the Simplified Erosion Partial Recording System (SEPRS).

Results

DE was clinically diagnosed in 28.3% of 15 years old and 34.3% of 17 years old. Severe erosive wear (grade 3 and 4 according to SEPRS) was found in 18.3% of the adolescents based upon the intra-oral photographs. DE was more prevalent and severe among males than females. Clinically diagnosed erosive lesions correlated significantly with soft drink consumption (p < 0.001), the use of juice or sport drinks as a thirst quencher after exercise (p = 0.006) and tooth hypersensitivity when eating and drinking (p = 0.012). Furthermore, self-assessed gastric reflux was a factor strongly associated with DE (p < 0.001).

Conclusion

The study indicated that DE was common among adolescents in Stockholm County and associated with both internal and external risk factors.

Longitudinal study of gastroesophageal reflux and erosive tooth wear

Background

Approximately 60% of patients presenting to dentists with erosive tooth wear have significant gastroesophageal reflux (GERD), despite minor reflux symptoms. No longitudinal studies of reflux-associated erosive tooth wear and of reflux characteristics have been reported to date.

The aim of this study was to characterize the longitudinal course of GERD and of associated erosive tooth wear, as well as factors predictive of its progression, in a large group of patients.

Methods

Seventy-two patients presenting to dentists with clinically significant erosive tooth wear and increased esophageal acid exposure by 24-h multichannel intraluminal pH-impedance measurement (MII-pH) were re-assessed clinically and by MII-pH after 1 year treatment with esomeprazole 20 mg twice-daily. Predictive factors for erosive tooth wear were assessed by logistic regression.

Results

At follow-up, no further progression in erosive tooth wear was observed in 53 (74%) of patients. The percentage of time with a pH < 4, the number of acid reflux episodes and the percentage of proximal esophageal reflux off-PPI did not change significantly after one year, but the number of weakly acidic reflux episodes decreased significantly in the large subgroup without progression. None of the baseline demographic, clinical, endoscopic or esophageal acid exposure characteristics were significantly associated with progression of erosive tooth wear at follow-up.

Conclusions

In this longitudinal study in patients with erosive tooth wear and oligosymptomatic GERD receiving esomeprazole for one year, erosive tooth wear did not progress further in the majority of patients. Background acidic esophageal reflux exposure appeared stable over time, whereas weakly acidic exposure decreased significantly in patients without erosion progression. MII-pH measurements on-PPI and with healthy controls will be useful in the further elucidation of the causal role of reflux in erosive tooth wear.

Trial registration

ClinicalTrials.gov, retrospectively registered: NCT02087345.

An updated review on gastro-esophageal reflux in pediatrics

Comprehensive guidelines for the diagnosis and management of gastro-esophageal reflux (GER) and GER disease (GERD) were developed by the European and North American Societies for Pediatric Gastroenterology, Hepatology and Nutrition. GERD is reflux associated with troublesome symptoms or complications. The recognition of GER and GERD is relevant to implement best management practices. A conservative management is indicated in infants with uncomplicated physiologic reflux. Children with GERD may benefit from further evaluation and treatment. Since the publications of the European and North American Societies for Pediatric Gastroenterology, Hepatology and Nutrition guidelines in 2009, no important novelties in drug treatment have been reported. Innovations are mainly restricted to the management of regurgitation in infants. During the last 5 years, pros and cons of multichannel intraluminal impedance have been highlighted. However, overall 'not much has changed' in the diagnosis and management of GER and GERD in infants and children.

Impact of CO2 laser and stannous fluoride on primary tooth erosion

This study evaluated in vitro the effect of input power of CO2 laser, either associated or not to stannous fluoride (SnF2) gel, for the control of intrinsic erosion in primary teeth. One hundred four enamel slabs (3 × 3 × 2 mm) from human primary molars were flattened and polished. Adhesive tapes were placed on their surface leaving a window of 3 × 1 mm. Slabs were then cycled four times in 0.01 M hydrochloric acid (pH 2, 2 min) and in artificial saliva (2 h) for creation of erosive lesions. Specimens were randomly assigned into eight groups (n = 13) according to fluoride application [absent (control) or 0.4% stannous fluoride gel (SnF2)] and input power of CO2 laser [unlased (control), 0.5, 1.0 or 1.5 W]. The CO2 laser irradiation was performed in an ultra-pulse mode (100 μs of pulse duration), 4-mm working distance, for 10 s. Specimens were then submitted to further erosive episodes for 5 days and evaluated for enamel relative permeability. Fluoride did not show any protective effect for any of the laser-treated groups or control (p = 0.185). However, a significant effect was detected for input power of CO2 laser (p = 0.037). Tukey's test showed that there was a significant statistically difference between specimens irradiated with 0.5 and 1.5 W (p = 0.028). The input power of 0.5 W showed lower permeability. Variation of input power CO2 laser can influence enamel permeability, at the power of 1.5 W which promoted greater permeability.

Impact of Acquired Pellicle Modification on Adhesion of Early Colonizers

New preventive approaches against dental erosion caused by acidic drinks and beverages include fortification of beverages with natural polymers. We have shown that the mixture of casein and mucin significantly improved the erosion-inhibiting properties of the human pellicle layer. This study aimed to investigate the effect of pellicle modification by casein, mucin and a casein-mucin mixture on the adhesion of early bacterial colonizers. Test specimens of human tooth enamel were prepared, covered with saliva and coated with 0.5% aqueous (aq.) casein, 0.27% aq. mucin or with 0.5% aq. casein-0.27% aq. mucin, after which the adhesion of Streptococcus gordonii, Streptococcus oralis, and Actinomyces odontolyticus was measured after incubation for 30 min and 2 h. log10 colony-forming units were compared by nonparametric tests. All three bacterial strains adhered in higher number to pellicle-coated enamel than to native enamel. The protein modifications of pellicle all decreased the counts of adhering bacteria up to 0.34 log10/mm2, the most efficient being the casein-mucin mixture. In addition to the recently shown erosion-reducing effect by casein-mucin, modification of the pellicle may inhibit bacterial adherence compared to untreated human pellicle.

Dental erosions and other extra-oesophageal symptoms of gastro-oesophageal reflux disease: Evidence, treatment response and areas of uncertainty

Extra-oesophageal symptoms of gastro-oesophageal reflux disease (GORD) are often studied, but remain a subject of debate. It has been clearly shown that there is a relationship between the extra-oesophageal symptoms chronic cough, asthma, laryngitis and dental erosion and GORD. Literature is abundant concerning reflux-related cough and reflux-related asthma, but much less is known about reflux-related dental erosions. The prevalence of dental erosion in GORD and vice versa, the prevalence of GORD in patients with dental erosion is high but the exact mechanism of reflux-induced tooth wear erosion is still under review.