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Restoration of Enamel and Dentin Erosion Due to Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a condition where acid contents of the stomach are regurgitated into the oral cavity, which results in continual exposure of the teeth to these acids. Knowledge of the relationship between GERD and dental erosion enables the appropriate diagnosis and treatment of the underlying medical condition as well as the affected teeth. This article details a case report where severe dental erosion was present due to GERD. After management of the disease, treatment (ie, diagnosis, treatment planning, and restoration) of the eroded dentition is described.

Most individuals experience gastroesophageal reflux at some time in their lives. Gastroesophageal reflux disease (GERD), however, is a clinical condition that occurs when the reflux of stomach acid into the esophagus is severe enough to impact the patient’s life and/or damage the esophagus. A relationship between GERD and dental erosion has been described in a number of publi­cations, but it was not until recently that the role GERD plays in the etiology of such a condition was described.1-5

Gastric juice reflux (gastroesophageal reflux [GER]) into the esophagus may occur in healthy individuals, usually after meals, and is associated with eructation or belching due to three possible mechanisms: 1) a transient, spon­taneous, or inappropriate relaxation of the lower eso­pha­geal sphincter that can be stimulated by factors such as diet, posture, exercise, and other causes; 2) a tran­sient increase in intra-abdominal or intragastric pressure; 3) a functional abnormality of the lower esopha­geal sphincter.6-9

In most patients, GERD is due to a transient relaxa­tion of the sphincter that keeps the lower end of the esopha­gus closed when he or she is not swallowing food or liquids, which allows acid and food particles to reflux into the esophagus. GERD is characterized by the chronic, intermittent, unrestricted movement of stomach acids into the esophagus. This is defined as regurgitation and should be distinguished from vomiting since it involves a passive or effortless return of the stomach contents into the mouth versus a physiological response to a stimuli controlled by the autonomic nervous system.3-5 The four major symptoms of GERD are: heartburn (uncomfortable, rising, burning sensation behind the breastbone), epigastric and retrosternal (noncardiac) pain, regurgi­tation of gastric acid or “sour stomach” contents into the mouth, and difficult and/or painful swallowing.3-5 At present, GERD is considered a chronic condition that cannot be cured. It can, however, be effectively managed with medication and lifestyle modifications. In severe cases, surgery is an option.

 

Gastroesophageal Reflux Disease and Oral Health

The frequent regurgitation of stomach acids into the mouth results in continuous undesired contact of these acids with the hard tissues of the oral cavity. This can cause dental erosion, a consequence of GERD that the dentist should understand and know how to treat. Erosion is different from abrasion in cause and appearance. Erosion is a nonbacterial chemical dissolution of hard tooth surfaces, whereas abrasion is caused by mechanical wear of tooth structure by external agents. The appearance of the lesions is differ­ent in that tooth surfaces affected by erosion have a smooth, spoon-shaped appearance, while abrasion lesions appear sharp, flat, and angular. Moreover, since erosion does not affect metal or plastic dental restorations as does abrasion, these remain as prominent elevated plateaus.10

Dental erosion can be the result of various systemic conditions, which often makes the etiology difficult to identify. These conditions include upper gastrointestinal disorders with an acid diet (43%), upper gastrointestinal disorders (25%), an acid diet (24%), eating disorders (6%), and unknown causes (2%).10 Unfortunately, the cause of dental erosion often goes undiagnosed, or the presence of other factors such as abrasion and attrition make diagnosis more difficult to determine.11

Bargen and Austin were the first to identify and report a relationship between dental erosion and gastro­intestinal disturbances in a case report of a woman who presented with chronic vomiting.12 The erosion was primarily evident on the palatal surfaces of the anterior maxillary teeth. Since the acids eroded the tooth structure with­out any evident damage to the restorative material, dental restorations in the oral cavity appeared prominent.3-5

Eccles and Jenkins found a relationship between erosion of the lingual surface of anterior teeth and GER.13,14 They suggested the following grading system for erosion: grade I = loss of enamel surface texture with no dentin involvement; grade II = erosion involving dentin for less than one third of the area of the tooth surface; and grade III = dentin erosion involving more than one third of the tooth surface.

Others have reported the cause and effect relation­ship between dental erosion and GERD. Jarvinen et al found an association between patients with dental erosion and an underlying pathosis (eg, reflux esophagitis, duodenal ulcer) in which acid secretion by the stomach was increased.1 Bartlett et al reported that there was a strong relationship between palatal dental erosion and GERD, even in those patients with no symptoms of reflux.3-5

The damage caused to the dentition by GERD depends on the severity of the case (ie, presence and frequency of regurgitation, duration of the reflux disease). In the majority of cases, the occurrence of pathological reflux was noted to occur during the day. These findings are consistent with many other studies. If regurgitation of the gastric juice occurs at nighttime, however, when salivary flow is at its lowest, the potential for damage to the teeth increases significantly.15

Several authors have reported a high incidence of erosion in patients with psychological and psychiatric disorders and those taking certain medications such as tranquilizers or beta-blocking agents. These medications produce a reduction of salivary secretion rate that contributes to dental erosion.16 While other investigators were unable to demonstrate a significant relationship between the use of anticonvulsant drugs and dental erosion,17 evi­dence suggested that this type of medication decreased the pressure of the lower esophageal sphincter, making such individuals more likely to suffer from reflux.16,17 In addition, according to several reports, GERD is more frequently found in patients with intellectual disabilities compared to an intellectually normal population.17

It has not been determined if the quality of oral hygiene has an effect on the severity of dental erosion.17

It has been reported, however, that mechanical factors such as occlusal wear, abrasive tongue action, and toothbrushing can potentiate the destructive nature of the acids.11 Ideally, the restoration of eroded tooth structure should occur following appropriate diagnosis and control of the etiology, and it should be oriented towards the reestablishment of function and aesthetics. Other researchers, however, emphasize the importance of early intervention before the progressive erosion makes it an almost impossible task or a full-mouth rehabilitation is necessary.17 This article presents a case report in which a severe generalized loss of enamel and dentin was present due to GERD.

 

Case Presentation

A 38-year-old Caucasian female patient presented to the clinic with a severe (grade III) generalized loss of enamel and dentin. The patient had a history of neurological complications (ie, seizures, schizophrenia). The patient’s mother had taken her to a dental office two years previously when the appearance of her teeth was a concern due to an extensive loss of enamel. The general dentist was the first to identify the relationship between the patient’s dental condition and possible GERD and referred her to a gastroenterologist. A full set of diagnostic examinations was performed; this included the monitoring of acid regurgitation and pH while the patient slept. Based on the results of this analysis, a final diagnosis of GERD was rendered.

The patient was treated with omeprazole, a gastric secretion suppressor that inhibits the hydrogen/potassium ATPase enzyme system in the gastric parietal cells of the lining of the stomach; it is considered a gastric acid pump inhibitor since it works by blocking the final step of acid production. The patient was under medi­cal evaluation for several months until the condition stabil­ized, at which point she was referred to the dental clinic for restorative treatment.

The patient’s current medications included: carbamazepine, an anticonvulsant (200 mg/day); olanzapine, an antipsychotic (10 mg/day at night); and omeprazole, a gastric acid inhibitor (20 mg/day). Clinical examination revealed almost complete loss of buccal and lingual enamel on the maxillary anterior teeth with thinning and chipping of the incisal edges (Figures 1 and 2). In addition, there was loss of enamel on the facial surfaces of the mandibular anterior teeth (Figures 3 and 4). Arch malalignment existed in the maxillary and the mandibular dentition. In spite of the erosion and generalized dentin exposure, no sensitivity was reported. The erosion affecting the posterior teeth was most severe on the left side (Figure 5) on which the patient reportedly slept.

Tooth structure loss was primarily observed on the buccal and occlusal surfaces of both premolar and molar teeth. The patient’s occlusion was maintained by previously placed posterior occlusal amalgam restorations, which prevented loss of the vertical dimension. Due to exposed dentin, the shade of the teeth was A3.5 (Vita shade guide). Although the patient desired aesthetic enhancement, night guard vital bleaching was declined due to her refusal to wear the bleaching trays.

Diagnostic data that consisted of preoperative photo­graphs, a complete radiographic survey, detailed clinical examination, alginate impressions for diagnostic models, a face-bow measurement, and interocclusal records were obtained. Based upon the information gathered, a treatment plan was proposed and accepted at a subsequent appointment.

(Continued from page 1 )

Treatment Plan

The models were mounted on a semiadjustable articulator, and a diagnostic waxup was made to determine optimum treatment. All-ceramic crowns and veneers (shade A1) were proposed for the maxillary and mandibular anterior teeth to reestablish the lost anterior guidance with optimal aesthetics. There was a discrepancy in the gingival margin of teeth #8 and #9, but after consultation with the periodontist, it was decided that surgery was not an option for this patient.

Restorations for the posterior teeth were selected based upon erosion patterns and the principle of tooth structure conservation. The use of all-ceramic restorations, as well as direct and indirect composite restorations, has been documented for the treatment of the eroded den­ti­tion in different clinical scenarios that include erosion due to gastric acid exposure. These restorative materials have allowed for a conservative approach when reestablishing function and aesthetics.18-22 Bonded reverse three-quarter Ceromer crowns were proposed for teeth #4, #12 through #14, #18 through #21, and #28 through #30. An all-ceramic crown was proposed for tooth #5 because of extensive erosion; an indirect resin inlay was proposed for tooth #15 due to the size of the previous restoration. Direct composite resin restorations were proposed for teeth #2, #3, and #31 for maximum tooth structure preservation.

A 0.12% chlorhexidine gluconate oral rinse was prescribed to help control plaque and reduce gingival inflammation during both the provisionalization phase and cementation of the definitive restorations.

 

Treatment Sequence

The patient was cooperative but had some limitations in keeping her mouth open for long periods. Treatment was consequently divided into the following phases: 1) preparation, impression, and cementation of anterior restorations, 2) preparation, impression, and cementation of the posterior indirect restorations, and 3) delivery of the direct composite resin restorations.

Provisional restorations were constructed using a clear template fabricated from the waxed-up stone models. Teeth #6 to #11 were prepared for all-ceramic crowns (Figure 6); provisional restorations were made using composite resin as a facial veneer lined with temporary material. A final impression was taken with a light- and medium-bodied polyvinylsiloxane impression material. Face-bow measurements, as well as interocclusal and excursive records, were obtained to replicate appropriate functional relationships.

All restorations were cemented using a primer/adhesive bonding system and dual-cure cement in a translucent shade (Figure 7). Once the maxillary crowns were cemented, the mandibular anterior teeth were prepared for the porcelain veneer restorations (Figure 8). Since the majority of the preparations were on enamel and there was no sensitivity on dentin-exposed areas, provisionalization was not necessary. The same procedure was followed for impression, inter­occlusal record registration, and cementation of the veneer restorations (Figure 9).

The posterior teeth were prepared by quadrant. Once the maxillary left side was prepared according to the treatment plan and provisionalized (Figures 10 and 11), the mandibular left side was prepared (Figure 12). Final impressions of both arches were taken with a light- and medium-bodied polyvinylsiloxane impression material. The restorations were fabricated at one time for optimal occlusal relations and were cemented at a subsequent appointment (Figures 13 and 14).

This same treatment sequence was used for the right pos­terior quadrants (Figure 15). These indirect resin restorations were also fabricated at one time for optimal occlusal relations and were cemented at the following appointment (Figures 16 and 17).

Direct resin composite restorations were performed for teeth #2 (Class I), #3 (Class II MOD), and #31 (Class I OB). For these restorations, an A2 dentin shade of composite resin was applied and covered with a translucent enamel shade for the final occlusal layer (Figures 17 and 18). Conservative restoration of the eroded teeth should provide the patient with excellent long-term function and aesthetics (Figures 19-20-21-22-23).

Discussion  

In patients who present with reflux episodes, the primary concern is the frequent presence of gastric juice in the mouth, which directly contacts the teeth and results in the dissolution of tooth structure. Many patients with long-term GERD may become symptom-free but continue to have reflux, which makes diagnosis difficult. Such patients have been described as “silent refluxers” and the first obvious sign is often dental erosion. Thus, the practitioner may be the first to identify such a condition. Since dental erosion is irreversible, the goal at this point should be immediate referral of the patient to a gastro­enterologist, who can more precisely confirm the diagnosis and begin treatment of the disorder.

According to Richter,23 ambulatory 24-hour pH monitoring is the most reliable method for diagnosing GERD. If positive, treatment that generally consists of medication should be promptly instituted. GERD, however, has a cyclical nature with periods of remission and relapse, which might provide a false-negative result. In these instances, dental erosion is essential to the final diagnosis.

Many options (eg, routine preventive and oral hygiene procedures) have been suggested for dental maintenance. Topical fluoride applications during follow-up dental appointments and the use of a 0.05% neutral pH sodium fluoride daily mouthrinse are recommended. In some cases, bicarbonate rinsing might help buffer the acidic effect in the oral cavity.10,11 Since this patient showed an inconsistent behavior in terms of rinsing and oral hygiene procedures, a 1.1% neutral sodium fluoride toothpaste was prescribed.

Compliance is not always readily obtained from many patients with normal mental conditions, which makes it an added concern when treating mentally challenged individuals.

 

Conclusion

This case presentation should assist the dental professional in the proper diagnosis and management of a challenging disorder (ie, GERD) and its dental manifestations. Regular follow-up will be performed to evaluate the long-term function and aesthetics of the dental restorations placed and to prevent further enamel and dentin erosion.

*Adjunct Faculty, Department of Operative Dentistry, University of Iowa, Iowa City, Iowa.

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