|Year : 2016 | Volume
| Issue : 2 | Page : 154-159
Association between dental erosion and possible risk factors: A hospital-based study in gastroesophageal reflux disease patients
Vamsi Krishna Reddy, Piyali Poddar, Shafaat Mohammad, Sabyasachi Saha
Department of Public Health Dentistry, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh, India
|Date of Web Publication||10-Jun-2016|
Department of Public Health Dentistry, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Gastroesophageal reflux disease (GERD) is a condition, with a prevalence of up to 10–20% in the general population. GERD may involve damage to the oral cavity, and dental erosion may occur with a higher frequency. Aim: To estimate the prevalence of dental erosion in GERD patients and to evaluate the association between dental erosion and possible risk factors. Materials and Methods: The study was conducted in the Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow among patients attending outpatient department between June and August 2014. The study group comprised 91 subjects with GERD and 114 subjects without GERD. Information regarding symptoms of GERD, medicines, any chronic disease, and dietary habits were recorded. Dental examination was done to assess the presence or absence of dental erosions and its severity was measured using O'Sullivan Index (2000). Statistical analysis was done using Mann–Whitney U-test and Kruskal–Wallis test. Results: Of 91 GERD patients, 87 (95.6%) patients had dental erosion. In both groups, association between frequent intake of fruit juice, carbonated drinks, milk, yoghurt, fruits, and tea/coffee with occurrence of dental erosion were statistically significant (P < 0.05). In GERD patients, association between intake of milk and occurrence of dental erosion were statistically significant (P < 0.05). Association of medication with dental erosion was found to be statistically significant (P < 0.05). Chronic diseases like diabetes and asthma were also found to be statistically significant with dental erosion (P < 0.05). Conclusion: This study showed that GERD patients were at increased risk of developing dental erosion compared to controls.
Keywords: Dental erosion, gastroesophageal reflux disease, O'Sullivan Index
|How to cite this article:|
Reddy VK, Poddar P, Mohammad S, Saha S. Association between dental erosion and possible risk factors: A hospital-based study in gastroesophageal reflux disease patients. J Indian Assoc Public Health Dent 2016;14:154-9
|How to cite this URL:|
Reddy VK, Poddar P, Mohammad S, Saha S. Association between dental erosion and possible risk factors: A hospital-based study in gastroesophageal reflux disease patients. J Indian Assoc Public Health Dent [serial online] 2016 [cited 2019 May 25];14:154-9. Available from: http://www.jiaphd.org/text.asp?2016/14/2/154/183814
| Introduction|| |
Over recent decades, an increasing interest has been observed in dental disorders other than dental caries and periodontal diseases which involve tooth wear or loss of tooth surface including dental erosion. Renewed interest in the study of tooth wear, and especially of erosion, began in the 1980s. Dental erosion is defined as the loss of tooth structure through a physicochemical process of dissolution of hard dental tissue in association with acidification in the oral cavity, without bacterial activity. The extent of damage may range from a barely noticeable loss of surface luster evident on clean, dry enamel to the partial or complete exposure of dentine with its characteristic yellow color through the thinned overlying enamel. Erosion affects all surfaces of the teeth and can lead to discoloration, tooth sensitivity, shortened or rounded teeth, fractured teeth, and even tooth loss.
The etiology of dental erosion is multifactorial. The causes may consist of extrinsic acids (acidic foods, beverages, or drugs) or intrinsic factors, the most common being gastroesophageal reflux disease (GERD) with regurgitation of gastric acid into the oral cavity. Refluxed acid first attacks the palatal surface of the upper incisors; in the secondary stage, if the condition continues, erosion of the occlusal surfaces of the posterior teeth in both arches occurs. The labial or the buccal surfaces are affected by erosion only if acid reflux persists for an extended period. Researchers have concluded that the force of the regurgitation passing from the pharynx into the mouth may influence the severity of dental erosion. Dentists can help in early diagnosis of patients who have unexplained dental erosions. Therefore, dentists should be more aware of the various manifestations of GERD in both children and adults.
Only a few studies  have been conducted in India to assess the association between GERD and dental erosion. Hence, this study has been undertaken with an aim to estimate the prevalence of dental erosion in GERD patients and to evaluate the association between dental erosion and possible risk factors.
| Materials and Methods|| |
A hospital-based cross-sectional study was conducted in the Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, UP between June and August 2014. Ethical clearance was obtained from the Institutional Ethical Committee and also from Sanjay Gandhi Post Graduate Institute of Medical Sciences. Informed consent was taken from each participant prior to the study.
The study group comprised 91 subjects with GERD of 20 years and above. New patients who visited the hospital during the study period who were diagnosed with GERD clinically were then confirmed by endoscopy and 24-h pH metry test. They were compared with 114 subjects without GERD attending General Medicine outpatient department of the same institute during the same time.
A pilot study was conducted on 10 subjects who did not participate in the main study to check the validity of the questionnaire and operational feasibility of the study. Cronbach's alpha was applied for the reliability of the questionnaire and was found to be 0.84.
Patients having typical symptoms (heartburn, epigastric pain, vomiting) or atypical symptoms (asthma, chest pain, etc.,) and suspected with GERD were confirmed by endoscopy and 24 h pH metry test and were included in the study. Patients with previously diagnosed dental pathologic features or who had previous orthodontic interventions or the subjects having the habit of chewing tobacco were excluded from the study.
The study was carried out by a single investigator who was trained and calibrated before the commencement of the study, and the kappa coefficient was estimated to be 0.86. The proforma consisted of 2 parts:
First part comprised of structured closed-ended questionnaire regarding symptoms of GERD, medicines, any chronic disease and dietary habits was recorded by interviewing the patient. The questionnaire consisted of three sections.
- The first section included demographic details such as name, age, gender, residential address, education, occupation, and income of the subjects
- In the second section, information was gathered on medical history like symptoms of GERD-recurrent vomiting, heartburn, epigastric pain, and any other atypical symptoms like asthma and presence of any other chronic disease and medication history
- In the third section, dietary history was recorded regarding consumption of fruits and beverages-fruit juice, carbonated drinks, milk, yoghurt, fruits, tea/coffee, iron tonics.
The second part consisted of clinical examination for recording dental erosion according to their clinical appearance using O'Sullivan Index (2000). Every tooth was examined and assigned a three-digit score relating to the site of erosion, severity (grade 0–5) and area of surface affected. Each subject was examined as per ADA Type III criteria.
The data collected was coded and tabulated and subjected to appropriate statistical analysis using SPSS version 16.0. Statistical analysis was done using Mann–Whitney U-test and Kruskal–Wallis test to see the association between beverages and dental erosion. Chi-square test was used to test the association between medication and dental erosion and presence of chronic disease and dental erosion.
| Results|| |
[Table 1] shows that out of 91 GERD patients, 87 (95.6%) patients had dental erosion. In [Table 2], it was observed that association between frequent intake of fruit juice, carbonated drinks, milk, fruits, yoghurt, and tea/coffee was statistically significant (P< 0.05) with the occurrence of dental erosion in both GERD patients and subjects without GERD. In GERD patients, association between intake of milk and occurrence of dental erosion was statistically significant (P< 0.05). Medication history was statistically significant with dental erosion (P< 0.05) [Table 3]. It was observed that association of chronic diseases like diabetes and asthma with dental erosion was statistically significant [Table 4].
[Figure 1] shows that 87 subjects had erosion in occlusal surface followed by palatal, multisurface, labial, and occlusal then labial surface. [Figure 2] shows severity of dental erosion in GERD patients. Loss of enamel only or loss of surface contour was observed in 75 patients followed by loss of enamel with exposure of dentine. Then followed matt appearance of enamel surface with no loss of contour with 67 number of patients. 48 patients showed loss of enamel and dentine beyond dentino-enamel junction and only 20 subjects showed loss of enamel and dentine with exposure of the pulp.
|Figure 1: Number of subjects with tooth surfaces affected by dental erosion in GERD patients|
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| Discussion|| |
In this study, there was a significant association between GERD and dental erosion. The acidic stomach content refluxed into the oral cavity can dissolve tooth structures and ultimately cause erosive tooth wear. This finding was similar to studies by Holbrook et al., Oginni et al., Bartlett et al., Schroeder et al., and Meurman et al. Holbrook et al. in Iceland found a significant association between diagnosed GERD and dental erosion. Oginni et al. in Nigeria also noted that tooth wear index scores were higher in patients with GERD than in control subjects. Their study supported the consideration of dental erosion as the extra-oesophageal manifestation of GERD. Bartlett et al. in England observed pathological levels of reflux in 60% of patients with tooth wear. In a study by Schroeder et al. on patients with tooth wear, 80% of them were diagnosed with reflux. Meurman et al. in Finland reported that tooth wear and GERD were interrelated.
Dental erosion was measured using O'Sullivan index. This index was the most recent among all the indices used for dental erosion. The index was qualitative with a broad attempt at quantification noting whether less or more than half of the surface was affected.
In this study, the age group selected was 20 years and above. In a study by David, they concluded that GERD can occur at any age and might cause erosion of the enamel because of hydrochloric acid contact with the enamel when the stomach contents return into the mouth. According to Moazzez et al., acid reflux in GERD patients can lead to erosion, and gum chewing which increases swallowing cycles, can help empty esophagus, and thus reduce acidic postprandial esophageal reflux.
In the present study, there was an association of extrinsic factors such as carbonated drinks, fruits, and tea/coffee with dental erosion. Soft drinks, including carbonated beverages and fruit juices, are almost exclusively acidic (pH < 4.0). These beverages, when in contact with the tooth, will reduce the pH at the tooth surface to a level below the critical value of 5.5 for enamel demineralization. Erosion starts with enamel surface softening in the early stage, and enamel tissue loss develops progressively with continued erosive challenges. Softened enamel is susceptible to abrasive wear. These findings were similar to studies by Künzel et al., Owens and Kitchens  and Harnack et al. Künzel et al. concluded from a study in Cuba that vinegar, pickles, carbonated beverages, and acidic drinks (such as citrus juices) are frequent causes of dental erosion. Studies by Owens and Kitchens  in the United States and Harnack et al. among US children and adolescents found a positive correlation between dental erosion and the consumption of soft drinks.
American Dental Association (2008) named some factors which start or worsen dental erosion: Drinks, GERD and maintaining aspirin and Vitamin C tablets in the mouth for long periods of time. There was association between medication and dental erosion. Medications that are acidic in nature such as those containing Vitamin C and aspirin can cause erosion through direct contact with the teeth when the medication is chewed or held in the mouth prior to swallowing. Habitual use of mood-enhancing drugs such as ecstasy may also increase the risk for erosive tooth wear. Studies ,, have shown that erosion may be associated with low salivary flow and/or low buffering capacity. The dry mouth condition is usually related to aging, even though some other studies have not found this correlation. It has been established that patients taking medication can also present decreased saliva output.
In the present study, dental erosion was significantly associated with asthma, diabetes, and any other disease like heart diseases which is similar to the study done by Vakil et al. Wang et al. in a study found an increased prevalence of tooth erosions was significantly associated with an increased frequency of respiratory symptoms in a clinical study of 88 carefully selected adult patients with medically confirmed GERD. Thomas et al. also reported strong association between asthma and tooth erosion. These associations are linked to the systemic effects of ingested and inhaled drugs in decreasing the saliva flow and lower esophageal sphincter tonus and to the acidic nature of powdered topical drugs contained in puffers that are used to treat asthma.
In this study, it was found that occlusal surface was mostly affected by dental erosion. The results of previous investigations confirm the occurrence of such occlusal erosion patterns in patients with GERD. Dental erosion is multifactorial; but, distinguishing between individual influences of erosion, attrition, and abrasion is challenging. Young proposed that erosion, exacerbated by attrition and abrasion, is the main cause of tooth wear. In patients with GERD, acid refluxate causes tooth surface to soften, and mechanical insult, which may accelerate the wear process of softened tooth surfaces, is added by chewing. A study by Tantbirojn et al. conducted in Minneapolis found that tooth surface loss in participants with GERD could progress to a depth of tens of micrometers in only 6 months, that erosion due to GERD affects occlusal surfaces, and that the erosive tooth surface loss rate is twice as high in combination with attrition.
In contrast to the present study, a large case–control study by Di Fede et al. conducted on men and women aged from 19 to 78 years found no significant associations between GERD and either dental erosion or tooth sensitivity, but significant associations between GERD and xerostomia, oral acid/burning sensation, subjective halitosis, and erythema of the palatal mucosa and uvula. It was postulated that a significant portion of cases (with dental erosion) reported in the literature could have consisted of patients with a particularly abundant reflux or who were unresponsive to pharmacological therapy.
Yip et al. have showed that erosion is a major factor in tooth destruction in young population. They discovered acidic foods and reflux from the stomach as primary etiologic factors for emphasizing on prevention rather than treatment. Failure to diagnose early signs of erosive tooth wear can result in significant damage to the dentition and the masticatory system before treatment is sought. Therefore, early diagnosis and preventive management is important to prevent a lifetime of debilitating dentition and the need for complex restorative therapy. Imfeld  has suggested the prevention of dental erosion by reducing acidic food consumption, increasing saliva, fluoride administration, having foods with buffering activity, not to use materials and instruments which may erode the teeth and finally, appropriate restorations. Dentists may be the first person to diagnose the possibility of GERD, particularly in the case of “silent refluxers.” They often ask the patient's medical history and GERD is in concern because of its dental complications. With the cooperation of the dentist and the gastroenterologist, in addition to identifying the disease, teeth could be maintained for a longer period by an appropriate treatment plan.
The present study was hospital-based study using non-probability/convenient sampling. Further research can be undertaken using case–control study design with a larger sample size.
| Conclusion|| |
This study showed that dental erosion was more prevalent in GERD patients, and they were at higher risk of developing dental erosion. Beverages, chronic diseases like asthma and medications can also be risk factors for dental erosion. Therefore, it can be concluded that dental erosion has a high frequency in patients with GERD, and it should be considered as an extraesophageal manifestation of reflux.
We would like to express our gratitude to Dr. U. C. Ghoshal, Professor, and Dr. Arun, Senior Resident, Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow for their constant help and guidance. Our sincere thanks to all the volunteers/patients for their consent to take part in this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]