Longitudinal study of gastroesophageal reflux and erosive tooth wear

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 Risk of Dental Erosion in Patients with Gastroesophageal Reflux Disease: A Meta-Analysis

Aim: The present paper aims to systematize data concerning the prevalence and risk of dental erosion (DE) in adult patients with gastroesophageal reflux disease (GERD) compared to controls. Materials and methods: Core electronic databases, i.e., MEDLINE/PubMed, EMBASE, Cochrane, Google Scholar, and the Russian Science Citation Index (RSCI), were searched for studies assessing the prevalence and risk of DE in adult GERD patients with publication dates ranging from 1 January 1985 to 20 January 2022. Publications with detailed descriptive statistics (the total sample size of patients with GERD, the total sample size of controls (if available), the number of patients with DE in the sample of GERD patients, the number of patients with DE in the controls (if available)) were selected for the final analysis. Results: The final analysis included 28 studies involving 4379 people (2309 GERD patients and 2070 control subjects). The pooled prevalence of DE was 51.524% (95 CI: 39.742–63.221) in GERD patients and 21.351% (95 CI: 9.234–36.807) in controls. An association was found between the presence of DE and GERD using the random-effects model (OR 5.000, 95% CI: 2.995–8.345; I² = 79.78%) compared with controls. When analyzing studies that only used validated instrumental methods for diagnosing GERD, alongside validated DE criteria (studies that did not specify the methodologies used were excluded), a significant association between the presence of DE and GERD was revealed (OR 5.586, 95% CI: 2.311–13.503; I² = 85.14%). Conclusion: The meta-analysis demonstrated that DE is quite often associated with GERD and is observed in about half of patients with this extremely common disease of the upper gastrointestinal tract.

Relationship between erosive tooth wear and possible etiological factors among dental students

OBJECTIVES

The aim of this study was to assess the relationship between erosive tooth wear (ETW) and possible etiological factors in a group of dental students.

MATERIALS AND METHODS

A total of 126 dental students from a public dental school were included in this study. A questionnaire was used to investigate the possible etiological factors related to ETW. The Basic Erosive Wear Examination (BEWE) criteria were used to examine the status of ETW. A univariable and multivariable logistic regression models were used to assess the relationship between the presence of ETW and explanatory variables.

RESULTS

Univariable analysis revealed that taking acidic foods and alcohol more than 4-5 times per week increases the odds of ETW by 6.043 and 2.532 times, respectively, and taking dairy products, fruit juice, and milk more than 4-5 times per week decreases the likelihood of ETW by 61%, 66%, and 80%, respectively. The results of multivariable regression analysis showed that the frequency of consumption of especially acidic foods significantly increased the risk of ETW (OR = 9.981, 95% CI 3.577-27.849, p < 0.001).

CONCLUSIONS

Although the ETW status of dental students, who are the future dentists, varies depending on different possible etiological factors, especially the consumption of acidic foods has increased the risk of ETW approximately 10 times.

CLINICAL RELEVANCE

The findings highlight the high relevance of ETW, especially with acidic food consumption, and the importance of controlling potential etiological factors in dental students.

Tooth Wear Evaluation System (TWES) 2.0-Reliability of diagnosis with and without computer-assisted evaluation

BACKGROUND

Tooth wear is a multifactorial process, leading to the loss of dental hard tissues. Therefore, it is important to detect the level of tooth wear at an early stage, so monitoring can be initiated. The Tooth Wear Evaluation System (TWES) enables such a multistage diagnosis of tooth wear. The further developed TWES 2.0 contains a complete taxonomy of tooth wear, but its reliability has not yet been validated.

OBJECTIVES

The aim of the study was to examine in a randomised controlled trial (RCT) whether diagnoses made based on the TWES 2.0 are reproducible and whether this reproducibility is also achieved with computer-assisted diagnostics.

METHODS

44 dental students received extensive training in TWES 2.0 assessment and taxonomy. The students each evaluated at least 10 (of the present 14) anonymised patient cases using gypsum models and high-resolution intra-oral photographs according to TWES 2.0. One half initially evaluated on paper; the other half used dedicated software (CMDfact / CMDbrux). After half of the patient cases (5), the evaluation methods were switched (AB/BA crossover design). The diagnoses were then evaluated for agreement with the predefined sample solution.

RESULTS

Evaluation of agreement with the sample solution according to Cohen's kappa indicated a value of 0.46 for manual (traditional) evaluation; and 0.44 for computer-assisted evaluation. Evaluation of agreement between examiners was 0.38 for manual and 0.48 for computer-assisted evaluation (Fleiss' kappa).

CONCLUSION

The results of this study proved that the taxonomy of the TWES 2.0 has acceptable reliability and can thus be used by dentists. Accordingly, the system can be learned quickly even by untrained practitioners. Comparable results are achieved with computer-assisted evaluation.

Hyperemesis Gravidarum: Strategies to Improve Outcomes

Hyperemesis gravidarum (HG) is a debilitating and potentially life-threatening pregnancy disease marked by weight loss, malnutrition, and dehydration attributed to unrelenting nausea and/or vomiting; HG increases the risk of adverse outcomes for the mother and child(ren). The complexity of HG affects every aspect of a woman's life during and after pregnancy. Without methodical intervention by knowledgeable and proactive clinicians, life-threatening complications may develop. Effectively managing HG requires an understanding of both physical and psychosocial stressors, recognition of potential risks and complications, and proactive assessment and treatment strategies using innovative clinical tools.

Analysis of laboratory adhesion studies in eroded enamel and dentin: a scoping review

Aim

To summarize and report laboratory studies of adhesion in eroded substrates, which used bond strength as an outcome measure. To determine the strategies available to overcome bonding difficulties, the quality and consistency of the methodology and to find evidence gaps.

Materials and Methods

The present review followed PRISMA-ScR guidelines. A search was conducted on PubMed/Medline, Scopus and EMBASE (Ovid) databases to identify published peer-reviewed papers (2010–2020). For final qualitative synthesis, 29 articles were selected which respected the inclusion criteria. Data charting was carried out, independently, by two reviewers and quality assessment of the articles was performed.

Results

The primary studies included fall into four major categories: comparison of restorative materials and application modes, enzymatic inhibitors, surface pretreatments or remineralization strategies. Most studies found evaluated dentin (76%), while 17% evaluated enamel, and 7% evaluated both substrates. The majority of the studies reported an effective intervention (83%). Bond strength to eroded dentin is significantly reduced, while in enamel erosion is beneficial. The bond strength to eroded dentin is material-dependent and favored in systems containing 10-MDP. Great disparities among the erosion models used were found, with citric acid in different concentrations being the preferred method, although standardization is lacking.

Conclusions

Adhesives containing 10-MDP show beneficial results in eroded dentin, and surface preparation methods should be considered. Studies which evaluated adhesion to eroded enamel/dentin show high heterogeneity in what concerns aims and methodology. Strategies that focus on remineralizing dentin and strategies to protect bond longevity in this substrate require further research.

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.

Should dentistry be a specialty of medicine? Two viewpoints

Dentistry and dental education are well-established domains with deep-rooted institutions, educational programs, organizational structures, and advanced specialty fields. Almost 100 years ago, Dr. William Gies, founder of the Columbia University College of Dental Medicine, stated that to best serve the oral health needs of the population, dentistry should be considered a specialty of medicine, and dental students should have the same solid foundation in the basic and clinical sciences as medical students. More recently, the report on "Advancing Dental Education in the 21st Century" recommends an increase in the integration of dental and medical education as a means to address 2 of its key challenges: "shrinking demand for dental services" and "shifting practice environment." However, it has also been argued that making dentistry and dental education a subspecialty of medicine and medical education will create logistical, structural, regulatory, and financial dilemmas. Instead of a drastic change to current dental educational, organizational, and institutional models, some argue a contemporary approach to dental education is required to ensure dentists are well prepared to address the healthcare needs of the population and future healthcare delivery systems and practice models. Recognizing the need for change in dental education to keep pace with changes in patient demographics and healthcare systems, the dental profession has the responsibility and opportunity to develop new models and paradigms that improve educational and clinical outcomes in our educational programs and future practice.

Factors associated with dental erosions in gastroesophageal reflux disease: a cross-sectional study in patients with heartburn

Background and aim

Dental erosion (DE) represents a frequent condition in adults and the elderly. The gastroesophageal reflux disease (GERD) is considered an important endogenous factor causing dental erosions. The objective of this study was to assess the prevalence of DE in GERD patients and to establish the correlation between pathogenic intrinsic and extrinsic factors of DE and their relation to GERD.

Methods

A cross-sectional study was conducted on 263 patients (median age 43). Patients with heartburn were recruited in two countries with different prevalence of GERD. Patients were recruited from France (n=158, 60%) and Romania (n=105, 40%) including 163 females and 100 males. The Basic Erosive Wear Examination (BEWE) index for diagnosis and evaluation of dental erosion was used. Based on the value of BEWE score, each patient was included in a risk group for DE development (low risk: BEWE=3-8, medium risk: BEWE=9-13, high risk: BEWE ≥14). Patients filled a questionnaire regarding GERD symptoms, medications, life style. Salivary parameters (pH and buffering capacity) were also assessed and analyzed.

Results

DE was significantly more frequent and more severe in GERD subjects than in the non-GERD controls. Low salivary pH but not salivary buffering capacity was associated with BEWE scores. Buffering capacity however was significantly more altered in patients with BEWE score over 9 (medium DE) than in patients with mild DE (BEWE <9). Although extrinsic factors (consumption of citrus fruits, soda drinks) were associated with DE in GERD, there was no statistical correlation with the BEWE score. From the total of 263 patients, 229 (87.1%) presented BEWE score <9, and 34 (12.9%) presented BEWE ≥9. The DE was significantly associated with the presence of GERD (p<0.001). BEWE score >9 was more frequently present in GERD patients (30 patients: 21.3%) than in non GERD patients (4 patients: 3.3%). DE were more frequent in French subjects compared to Romanian subjects. Romanians had lower BEWE scores than the French.

Conclusions

DE is more frequent and more severe with GERD vs. non-GERD. DE in GERD is associated with extrinsic dietary factors like citrus fruits and soda drinks.

How to select patients for antireflux surgery? The ICARUS guidelines (international consensus regarding preoperative examinations and clinical characteristics assessment to select adult patients for antireflux surgery)

OBJECTIVE

Antireflux surgery can be proposed in patients with GORD, especially when proton pump inhibitor (PPI) use leads to incomplete symptom improvement. However, to date, international consensus guidelines on the clinical criteria and additional technical examinations used in patient selection for antireflux surgery are lacking. We aimed at generating key recommendations in the selection of patients for antireflux surgery.

DESIGN

We included 35 international experts (gastroenterologists, surgeons and physiologists) in a Delphi process and developed 37 statements that were revised by the Consensus Group, to start the Delphi process. Three voting rounds followed where each statement was presented with the evidence summary. The panel indicated the degree of agreement for the statement. When 80% of the Consensus Group agreed (A+/A) with a statement, this was defined as consensus. All votes were mutually anonymous.

RESULTS

Patients with heartburn with a satisfactory response to PPIs, patients with a hiatal hernia (HH), patients with oesophagitis Los Angeles (LA) grade B or higher and patients with Barrett's oesophagus are good candidates for antireflux surgery. An endoscopy prior to antireflux surgery is mandatory and a barium swallow should be performed in patients with suspicion of a HH or short oesophagus. Oesophageal manometry is mandatory to rule out major motility disorders. Finally, oesophageal pH (±impedance) monitoring of PPI is mandatory to select patients for antireflux surgery, if endoscopy is negative for unequivocal reflux oesophagitis.

CONCLUSION

With the ICARUS guidelines, we generated key recommendations for selection of patients for antireflux surgery.

Obesity and tooth wear among American adults: the role of sugar-sweetened acidic drinks

BACKGROUND

To explore the association between obesity and tooth wear among American adults and the role of sugar-sweetened acidic drinks consumption in explaining that association.

METHODS

We analyzed data from 3541 adult participants in the National Health and Nutrition Examination Survey. Obesity was determined using the body mass index and tooth wear was assessed using the modified tooth wear index. Daily intake of four categories of drinks was estimated as the average (drinks/day) of two consecutive 24-h dietary recalls. The association between obesity and number of surfaces with moderate-to-severe tooth wear was assessed in hurdle models adjusting for sociodemographic factors, acid reflux medication, and dental insurance.

RESULTS

Overweight and obese adults had more surfaces with moderate-to-severe tooth wear than those with normal body size, after adjusting for confounders. The consumption of sugar-sweetened acidic drinks explained part, but not all the above association. More specifically, the estimate for obesity was fully attenuated, whereas the estimate for overweight was slightly attenuated but remained significant.

CONCLUSION

Obesity was positively associated with tooth wear in American adults. This association was only partially accounted for by the consumption of sugar-sweetened acidic drinks, a common risk factor for both conditions.

PRACTICAL IMPLICATIONS

Dentists must be aware of the health consequences of sugar-sweetened acidic drinks and advocate for reduction in consumption and/or substitution with healthier alternatives.

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.

Gastro-oesophageal reflux - an important causative factor of severe tooth wear in Prader-Willi syndrome?

BACKGROUND

Prader-Willi syndrome (PWS) is the most common genetic human obesity syndrome and is characterized by hypotonia, endocrine disturbances, hyperphagia, obesity and mild mental retardation. Oral abnormalities, such as decreased salivary flow rates and extreme tooth wear, have also been described. Studies have shown a significant increase in reflux symptoms in individuals with obstuctive sleep apnoea syndrome and increased BMI, both of which are typical findings in PWS. Gastro-oesophageal reflux disease (GORD) has been identified in some individuals with PWS and is a significant intrinsic factor in dental tooth wear. The aim of this study was therefore to estimate the prevalence of GORD in adults and children and to evaluate a possible correlation between GORD and tooth wear in adults with PWS. They were all registered at the TAKO-centre.

RESULTS

Twenty-nine individuals, 17 adults with a mean age of 32.6 years (range 18-48) and 12 children with a mean age of 8.8 years (range 3-17), agreed to undergo 24-hour oesophageal pH monitoring, and 90% of those enrolled managed to complete the examination. Four children and eleven adults were diagnosed with pathological gastro-oesophageal reflux, which is defined as acid exposure (pH less than 4) more than 3.6 or 4.3 percent of the time, respectively. Manometry performed in the adult group showed a pathologically high lower oesophageal sphincter pressure in four of the five individuals who had normal oesophageal pH values (pH under 4 less than 4.3% of the time). The two groups (reflux and non-reflux) were well balanced according to BMI, genotype, tooth grinding and hyposalivation. However, twice as many individuals in the reflux group as in the non-reflux group reported high consumption of acidic foods and drinks. Increased tooth wear was significantly correlated with GORD in the two groups (reflux n=6 and non-reflux n=6).

CONCLUSIONS

The prevalence of gastro-oesophageal reflux is high in individuals with PWS. Tooth wear was strongly associated with GORD and acidic drinks, and both may be important aetiological factors underlying the extreme tooth wear in this group. Our data suggest a need for routine screening for GORD and dental wear in young individuals with Prader-Willi syndrome.