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Dental Erosion and Acid Reflux Disease

Patrick L. Schroeder, MD; Steven J. Filler, DDS; Belinda Ramirez, MD; David A. Lazarchik, DMD; Michael F. Vaezi, MD, PhD; and Joel E. Richter, MD
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From the University of Alabama at Birmingham, Birmingham, Alabama. Requests for Reprints: Joel E. Richter, MD, Department of Gastroenterology 540, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195. Acknowledgments: The authors thank Mrs. Debbie Poe for assistance with manuscript preparation and Mrs. Jean Price and Mrs. Susan Irwin for their efforts in the gastroenterology laboratory.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1995;122(11):809-815. doi:10.7326/0003-4819-122-11-199506010-00001
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Objective: To determine the relation between gastroesophageal reflux disease and dental erosion using ambulatory 24-hour esophageal pH testing.

Design: Cross-sectional observational study.

Setting: Tertiary referral center.

Patients: The dental group consisted of 12 patients with idiopathic dental erosion who were identified by dentists and screened for gastroesophageal reflux disease using 24-hour pH testing. The gastroenterology group consisted of 30 patients who had 24-hour pH testing in the esophageal laboratory and who were referred for dental evaluation (10 did not have reflux, 10 had distal reflux, and 10 had proximal reflux).

Measurements: 24-hour esophageal pH monitoring using a pH probe in the distal and proximal esophagus. Complete dental examination with particular attention to the presence and severity of dental erosion; plaque; gingival damage; and decayed, missing, and filled teeth. Analysis of saliva for pH, flow rates, buffering capacity, and calcium and phosphorus levels. Standardized questionnaire to ascertain possible causes of dental erosion and presence of reflux symptoms.

Results: Ten of the 12 patients in the dental group (83% [95% CI, 52% to 98%]) had gastroesophageal reflux on esophageal pH monitoring. Nine had distal and 7 had proximal reflux. Seven had reflux in the upright position only, 1 had reflux in the supine position only, and 2 had both upright and supine reflux. No saliva abnormalities were found. Ten patients had typical symptoms of gastroesophageal reflux, but dietary or mechanical problems that may have been causing dental erosion were not identified. In the gastroenterology group, upright reflux was seen in 5 of the 10 patients with distal reflux and in all 10 patients with proximal reflux. In addition, 40% of patients in the gastroenterology group (12 of 30) had dental erosion (4 of the 10 with distal reflux [40%], 7 of the 10 with proximal reflux (70%), and only 1 of the 10 without reflux [10%]; P = 0.02 for those with reflux compared with those without reflux). The cumulative dental erosion score correlated with proximal upright reflux when all 24 study patients with erosion were analyzed (r = 0.55 [P < 0.01]); this correlation was even stronger in the subgroup of 12 patients with abnormal amounts of proximal upright reflux (r = 0.84 [P = 0.001]).

Conclusion: Dental erosion is a common finding in patients with gastroesophageal reflux disease and should be considered an atypical manifestation of this disease.


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Figure 3.
Presence and severity of erosion.

Percentage of tooth surfaces affected by erosion and severity according to the Eccles and Jenkins scale in the dental group and in the gastroenterology subgroups. In patients with distal and proximal reflux on 24-hour esophageal pH monitoring, 21% and 29% of tooth surfaces, respectively, were affected by erosion. In the single patient without reflux who had erosion, only 5% of tooth surfaces were affected.

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Figure 4.
Correlation of erosion scores and proximal upright reflux.leftnrightPP

Relation between cumulative erosion scores and percentage of time that proximal upright pH was less than 4.0 in all patients with dental erosion ( ) and in the subgroup ( = 12) with abnormal amounts of proximal upright reflux ( ). Amounts of proximal upright reflux were defined as abnormal if the percentage of time that pH was less than 4.0 was more than 1.7%. Linear regression analysis found a relation ( < 0.01 and < 0.001, respectively) between erosion and proximal reflux in both groups.

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Figure 2.
Dental erosion.arrows

Mandibular facial surfaces showing smooth, glistening, yellow, “dished-out” erosion ( ).

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Figure 1.
Dental erosion and dental caries. Top.arrowsBottom.arrow

Extensive loss of enamel with exposed underlying dentin (yellow) characteristic of dental erosion ( ). Dental caries. Soft, discolored, irregular, carious lesions on interproximal surfaces of maxillary teeth ( ). Note thick, edematous, reddened gingival margins secondary to plaque accumulation.

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