Gastroesophageal reflux disease: New oral findings

doi:10.1067/moe.2001.111139

Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology

Volume 91, Issue 3, March 2001, Pages 301-310

https://doi.org/10.1067/moe.2001.111139 Get rights and content

Abstract

Objective: The objective of this study was to investigate the effects of gastroesophageal reflux disease (GERD) on dentition, salivary function, and oral mucosa. Study Design: Thirty-one patients with esophagitis underwent medical evaluation, which included taking their medical history, performing both an esophagogastroduodenoscopy and esophagus biopsy, and conducting a stomatologic examination. The latter consisted of an extraoral and intraoral physical examination, saliva tests (flow, buffer capacity, and pH), and biopsy and morphometry of the palatal mucosa, as well as taking a history of the patients’ habits. Fourteen healthy volunteers from the same population were used as a control group. Results: No relationship between GERD and changes in the oral cavity was shown by saliva tests, oral clinical examination, or histopathologic examination of the palatal mucosa. However, morphometric analysis of the palatal epithelium showed a statistically significant difference between the patients with GERD and the control group. Conclusions: GERD is associated with microscopic alterations in the palatal mucosa (epithelial atrophy and increased fibroblast number), which are only detected by morphometry. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:301-10)

Section snippets

Subjects

Among the 5427 individuals referred to the Gastroenterologic Clinic of Bauru (UNIGASTRO) for esophagogastroduodenoscopy, 31 patients with GERD and 14 control subjects who met the recruitment criteria were selected. The criteria established the following: (1) patients had to accept and sign a consent to participate in the study; (2) patients had to have at least 20 teeth in the mouth, including the upper anterior teeth (first premolar to first premolar); (3) female patients could not be

Results

Table II shows that patients with GERD were older than the controls, and most of them were men.

. Basic data for the sample

Empty Cell	Patients	Controls
Sample (n)	31	14
Sex
M	20 (64.5%)	6 (43.0%)
F	11 (35.4%)	8 (57.0%)
Age (mean)	37.1 (20-61)	28.0 (16-49)

χ² = 1.07; P = .300.

However, application of the χ² test showed that there was no association between GERD and male or female gender.

Table III shows the histopathologic test results from the biopsy specimens taken from the esophagus.

. Microscopic classification of patients

Discussion

Only one typical case of dental erosion was observed (Fig 4).

. Erosion of palatal side with glossy surface. Palatal view.

However, this patient, in addition to having severe reflux (grade IV esophagitis), reported recurrent vomiting for a period of 10 years. Therefore, the chronic vomiting was probably the main cause of his erosion, as already established in the literature.48, 49, 50 Our results regarding dental erosion did not agree with those reported by others.7, 11, 14, 15, 29, 51, 52, 53 In

Conclusions

Our results have not proved a relationship between dental erosion and GERD. The saliva tests (sialometry, buffer capacity, and pH) did not show any significant difference between patients with GERD and controls. The clinical and histopathologic examination of the palatal mucosa did not show any changes resulting from GERD. GERD was shown to be associated with microscopic changes in the palatal mucosa, which are detectable by morphometric examination. The alterations were greater in the presence

Acknowledgements

We extend our appreciation to Dr José Roberto Lauris, statistician, for his invaluable help in analyzing the data.

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Gastroesophageal reflux disease and dental erosion: The role of bile acids
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In fact, long-term treatment with acid-suppressive medications such as esomeprazole appears to stop the progress of dental erosion (Wilder-Smith, Materna, Martig, & Lussi, 2017). In GERD patients, apart from gastric acid and pepsin, gastroesophageal reflux may contain bile acids, represented by a complex mix of conjugated and unconjugated acids (Silva et al., 2001). It is known that bile acids can damage the esophageal mucosa and may participate in the genesis of Barrett’s metaplasia (Menezes & Herbella, 2017; Tack, 2006).
To identify the bile acids in the saliva of patients with and without gastroesophageal reflux disease (GERD), and evaluate their effect on tooth surface.
A cross-sectional study involved 26 GERD patients and 40 controls without GERD. Dental erosions were identified, saliva was collected and analyzed with chromatography for bile acid identification. An in vitro study assessed the effect of enamel exposition to taurocholic acid in concentrations of 1 µM, 10 µM, and a mixture of taurocholic acid and glycocholic acid at 10 µM on enamel microhardness, calcium release, and surface topography.
Salivary bile acids were analyzed from 22 GERD patients and 40 controls. All these participants presented taurocholic acid and glycocholic acid in the saliva. The salivary amount of taurocholic acid was greater than glycocholic acid in both GERD patients (area under the curve: 7946 vs. 1361; p < 0.001) and controls (10,815 vs. 1290; p < 0.001). The salivary amount of taurocholic acid was greater in controls than in GERD patients (10,815 vs. 7946; p < 0.001). Dental erosion was more prevalent in GERD patients than in controls (27% vs. 7%; p = 0.041). In the GERD presence, the amount of glycocholic acid was greater in patients with dental erosion (1777 vs. 1239; p = 0.041). Enamel exposed to taurocholic acid at 10 µM, combined or not with glycocholic acid, had their microhardness increased, accompanied by calcium release, with no changes in surface topography.
Taurocholic acid was the predominant salivary bile acid, particularly in controls without GERD. This bile acid had no deleterious effect on the enamel structure.
Individuals With Gastroesophageal Reflux Disease or Symptoms May Have Increased Odds of Erosive Tooth Wear
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Helicobacter pylori and gastric hyperacidity, and their association with recurrent aphthous stomatitis
2020, International Journal of Oral and Maxillofacial Surgery
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The clinical symptom of gastric hyperacidity (heartburn) can be a manifestation of gastroesophageal reflux disease (GERD). The gastric refluxate seen in GERD has been associated with oral mucosal changes at the clinical level, which include erythema and mucosal atrophy affecting mainly the uvula and palatal mucosa25–27. Kim et al.28 investigated histological and molecular changes in children with tonsillar hypertrophy and found an increase in the expression of proinflammatory cytokines as a result of gastric pepsin by comparison to adults with tonsillitis.
Helicobacter pylori is an established cause of gastric ulcers. Its role in causing recurrent aphthous stomatitis (RAS) remains controversial. Fifty-two RAS patients and 52 sex-matched controls were recruited in this case–control study. All subjects were screened for hematinic deficiencies and H. pylori. The latter was assessed quantitatively using the ¹⁴C-urea breath test. The χ² test and Wilcoxon signed ranks test were used to compare H. pylori and hematinic indices between cases and controls, while conditional logistic regression was used to assess the associations between the occurrence of RAS and independent factors. H. pylori was positive in 56.7% of the overall sample, with no difference between RAS patients (50.8%) and controls (49.2%) (P = 0.843). The median H. pylori and haematological indices values did not show any association with ulcer diameter, number, or frequency. Interestingly, gastric hyperacidity was significantly associated with RAS, and this association was independent from tobacco smoking, alcohol drinking, and H. pylori (odds ratio 14.99, 95% confidence interval 2.47–90.95; P = 0.003). This study found no association between H. pylori and RAS. The association between RAS and gastric hyperacidity suggests that gastric refluxate, not H. pylori, has an effect on the oral mucosa that favours an ulcerative change.
The association between erosive toothwear and gastro-oesophageal reflux-related symptoms and disease: A systematic review and meta-analysis
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The source of the acid can be intrinsic, including gastro-oesophageal reflux or extrinsic and can be further exacerbated by reduced saliva flow [8,9] and supine positioning when sleeping [10]. Studies suggest that an intraoral pH below 5.5 can initiate the dissolution of the superficial enamel layer and may lead to erosive toothwear as well as hypersensitivity of the teeth and mucositis [7,8]. Erosive toothwear is common as epidemiological studies estimate the average prevalence of erosive toothwear worldwide ranges from 30 to 50%, reflecting the magnitude of this disease [8,11,12].
To conduct a systematic review and meta-analysis to explore the association between erosive toothwear and gastro-oesophageal reflux disease or symptoms (GERD/S).
Electronic searches were performed in Scopus, Embase, and Web of Science databases for the identification of relevant studies, from 1980 until 2nd August 2019.
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.
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.
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.
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.
Photographic Objective Alterations for Laryngopharyngeal Reflux Diagnosis
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Laryngopharyngeal reflux (LPR) is an advanced stage of gastroesophageal reflux where the backflow is so strong that the gastric contents pass through the upper esophageal sphincter and actually enter the laryngopharyngeal regions.2 LPR can lead to various ailments such as ulcers in the oral cavity, gingivitis, caries and tooth malformations, ulcerative lesions of the oral mucosa, chronic rhinosinusitis, asthma, chronic interstitial pulmonary diseases, and sudden infant death.3 LPR is also associated with various otolaryngological pathologies and symptoms like chronic laryngitis, contact ulcers and granulomas of the larynx, nodules of the vocal cords, Reinke edema, subglottic stenosis, laryngotracheal stenosis, paroxysmal laryngeal spasms, chronic coughing, globus pharyngeus, and laryngeal and hypopharyngeal carcinomas.1,4–6
Diagnosis of laryngopharyngeal reflux (LPR) in clinical practice is generally made subjectively based on history, symptoms, and endoscopic assessment. This study presents the diagnostic role of the digital photographic assessment of the laryngopharyngeal region for LPR.
Seventy-two patients with LPR symptoms and 35 healthy volunteers were evaluated using the Reflux Finding Scores (RFS) and the Reflux Symptom Index (RSI). The results of these scales were recorded in 72 patients representing group 1 with LPR diagnosis; they returned after 1 and 2 months of treatment as groups 2 and 3, respectively. Thirty-five volunteers represented group 4. Laryngopharyngeal regions of all subjects were examined and photographed endoscopically. Red, green, and blue (RGB) values of particular oropharyngeal and laryngeal points were measured.
RSI and RFS values of group 1 were significantly different from the other three groups, as were the scores of group 2; however, the comparison of the RSI and RFS values of groups 3 and 4 did not reveal a statistically significant difference. Laryngopharyngeal RGB values also duplicated statistical significance as above.
Measurement of RGB values can be a cheap and easy-to-use method to quickly provide objective and corroborative information to help in the diagnosis of LPR in conjunction with subjective methods.
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^*: Supported in part by a grant from FAPESP (#95/8953-7), awarded to Dr José Humberto Damante.

^**: This study was part of the requirements to fulfill the PhD program at Bauru Dental School, University of São Paulo.

^*: This study is part of the requirements to fulfill the PhD program at Bauru Dental School, University of São Paulo.

^**: Reprint requests: José Humberto Damante, DDS, MS, PhD, Al Octávio Pinheiro Brisolla, 9-75 CP-73, 17043-101, Bauru-São Paulo, Brazil, [email protected]

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Oral MedicineGastroesophageal reflux disease: New oral findings*,**,*,**

Abstract

Section snippets

Subjects

Results

Discussion

Conclusions

Acknowledgements

Oral Surg Oral Med Oral Pathol

Oral Surg Oral Med Oral Pathol

Oral Surg Oral Med Oral Pathol Oral Radiol Endod

J Am Dent Assoc Dent Cosmos

J Am Dent Assoc

J Am Dent Assoc

J Dent

J Am Dent Assoc

The pathogenesis of gastroesophageal reflux disease

Am J Roentgenol

In vitro study of enamel erosion caused by soft drinks and lemon juice in deciduous teeth analyzed by stereomicroscopy and scanning electron microscopy

Caries Res

Effect of effervescent vitamin C preparations on bovine teeth and some clinical and salivary parameters in man

Scand J Dent Res

Extraesophageal manifestations of gastroesophageal reflux disease

Am J Gastroenterol

Acid-reflux disorders

N Engl J Med

Otoryngological manifestations of gastroesophageal reflux: Diagnosis and treatment

Rev Bras Med Otorrinolaringol

Dental erosions caused by gastroesophageal reflux disease in children

J Dent Child

Oral regurgitation after reflux provoking meals: a possible cause of dental erosion?

J Oral Rehab

The voluntary reflux phenomenon

Brit Dent J

Baby fruit juices and tooth erosion

Brit Dent J

A study of the association between gastroesophageal reflux and palatal dental erosion

Brit Dent J

Role of salivary and seric epidermal growth factor in pathogenesis of reflux esophagitis in chronic alcoholics and nondrinkers

Dig Dis Sci

Aetiology, pathogenesis, and clinical manifestations of gastroesophageal reflux disease

Scand J Gastroenterol

Pathology of dental hard tissues

Dental erosion: its possible causes and treatment

Dent Cosmos

Perimylolysis. A contribution toward the genesis of tooth wasting from nonmechanical causes

Acta Odontol Scand

Etiology of dental erosion: intrinsic factors

Eur J Oral Sci

Dissolution of tooth substance by lemon juice, acid beverages and acids from some other sources

J Am Dent Assoc

Oral complications in anorexia nervosa

Scand J Dent Res

A comparison of patterns of tooth wear with aetiological factors

Brit Dent J

Depth and area of dental erosion, and dental caries in bulimic women

J Dent Res

Tooth surface loss from abrasion, attrition and erosion

Dent Update

The distribution and severity of tooth wear and the relationship between erosion and dietary constituents in a group of children

Int J Paediatr Dent

Dental erosion and acid reflux disease

Ann Intern Med

Oral Medicine
Gastroesophageal reflux disease: New oral findings*,**,*,**