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.
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
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.
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 )
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
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.
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
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).
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.
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
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