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Dental erosion caused by silent gastroesopheal

reflux disease
Article in Journal of the American Dental Association (1939) July 2002
DOI: 10.14219/jada.archive.2002.0269 Source: PubMed

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Dental erosion caused by silent

gastroesophageal reflux disease
DENA A. ALI, RONALD S. BROWN,
LUCIANO O. RODRIGUEZ, EDWARD L.
MOODY and MAHMOUD F. NASR
J Am Dent Assoc 2002;133;734-737

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734

IO
N

Dental erosion of the posterior teeth

is an important finding with respect to
the diagnosis of GERD and, especially,
silent GERD. Therefore, it is important
for dentists and physicians to evaluate
patients with dental erosion for acid
reflux. Prevalence, distribution and clinical appearance of dental erosion may
vary owing to regional, environmental
and behavioral factors and are estimated to occur in 2 to 18 percent of the
population. The finding of enamel erosion is divided relatively evenly between
the sexes.10 Schroeder and colleagues11
noted that 11 out of 20 patients who had
GERD (as determined by pH testing)
had dental erosion.

JADA, Vol. 133, June 2002

Copyright 2002 American Dental Association. All rights reserved.

Downloaded from jada.ada.org on March 23, 2009

ental erosion is an irreversible process characterized by mineral loss unrelated to microbial involvement, and it may be the secondary manifestation of systemic illnesses.1-5
Chemical dissolution of tooth structure may
be caused by diet, external sources common to industrial environments or internal sources such as regurgitation/reflux or vomiting.5 Gastroesophageal reflux disease, or GERD, is defined as involuntary muscle
relaxing of the upper esophageal
sphincter, which allows refluxed acid to
Dental erosion of move upward through the esophagus
the posterior into the oral cavity.2
Howden6 first reported the association
teeth is an
between GERD and dental erosion in
important finding
1971. He and others have reported that
with respect to dental erosion may serve as a diagnostic
the diagnosis of sign of acid reflux.6-8 Silent GERD refers
gastroesophageal to gastric reflux without symptoms such
reflux disease. as belching, unexplained sour taste or
heartburn. Patients who have undiagnosed silent GERD may manifest
gradual enamel erosion on their teeth, and dentists may
notice that they have unexplained erosion and sensitivity of the posterior dentition.7
Several factors are known to contribute to enamel
erosion. It occurs at a pH of approximately 5.5, which is
on the acidic side of the neutral point, and may vary
depending on the concentrations of calcium and phosphate ions within the saliva.4 Enamel erosion also has
been correlated directly with lowered salivary buffering
capacity.9

DENA A. ALI, D.D.S.; RONALD S. BROWN, D.D.S.,

M.S.; LUCIANO O. RODRIGUEZ, D.D.S., M.S.;
EDWARD L. MOODY, D.D.S.; MAHMOUD F. NASR,
B.D.S., D.D.S., M.S.

Background. Gastroesophageal reflux

disease, or GERD, is a relatively
common condition, in which
A D A
J
stomach acid may be

refluxed up through the

esophagus and into the
oral cavity, resulting in
N
C
enamel erosion. Symptoms A U I N G E D U
3
RT
such as belching, unexICLE
plained sour taste and heartburn
usually alert the patient to the condition. In
silent GERD, however, these symptoms do
not occur, and enamel erosion of the posterior dentition may be the first indication of
GERD.
Case Description. A 30-year-old man
came to a dental clinic with enamel erosion
on the occlusal surfaces of his posterior
teeth and the palatal surfaces of his maxillary anterior teeth. He reported no history
of gastrointestinal disease or heartburn.
Clinical Implications. Enamel erosion
may be a clinical sign of silent GERD that
allows the dentist to make the initial diagnosis. Referral to a physician or gastroenterologist is necessary to define the diagnosis; however, dental expertise may be
essential in distinguishing between differential diagnoses such as bulimia, attrition
and abrasion. Successful treatment of this
medical condition is necessary before dental
rehabilitation can be initiated successfully.
CON

Dental erosion
caused by silent
gastroesophageal
reflux disease

ABSTRACT

P R A C T I C E

C L I N I C A L

C L I N I C A L

Figure 1. Occlusal view of the maxillary teeth.

P R A C T I C E

Figure 2. Occlusal view of the mandibular teeth.

In this article, we present and discuss the case

of a patient with dental erosion secondary to
silent GERD.

occlusal tooth surfaces of the cusp tips of the posterior teeth.12-14 We evaluated the patients occlusion both clinically and with mounted study
models and found a decreased vertical dimension
CASE REPORT
secondary to enamel erosion. A full-mouth radioA 30-year-old man came to the Howard Univergraphic series and a panoramic radiograph
sity College of Dentistrys oral diagnosis clinic
revealed a uniform thinning of the enamel of the
with erosion of the occlusal surfaces of his posteocclusal surfaces of the posterior dentition, the
rior teeth and of the palatal surfaces of his maxillingual surfaces of the maxillary anterior dentilary anterior teeth. His chief comtion and Class II distal caries of the
plaints were the yellow
maxillary right second premolar
discoloration of his teeth and the
(Figure 3 and Figure 4).
We evaluated the
chipping of the incisal edges of his
We referred the patient to a gaspatients occlusion
incisors. His medical history was
troenterologist to be evaluated for
and found a
noncontributory. The patient
GERD. The report from the medical
decreased
vertical
denied having a history of gastroinevaluation confirmed a diagnosis of
dimension secondary
testinal problems, heartburn or
silent GERD and the endoscopy
showed epithelial irritation of the
experiencing a sour taste on awakto enamel erosion.
esophagus and a minimal hiatus
ening. He denied any history of
bulimia. There was no family hishernia. The gastroenterologist pretory related to gastritis or acid reflux. The patient
scribed to the patient omeprazole 20 milligrams
did admit to drinking lots of fruit juice and eating
per day and suggested that he elevate the head of
his bed and evaluate his dietary habits. The
spicy food.
physician also advised the patient to limit eating
When we clinically examined the patient, we
fatty and spicy meals, especially right before bedfound that he had good oral hygiene, thin translutime, and to avoid alcohol, caffeine, soft drinks,
cent enamel, loss of occlusal tooth structure and
yellow discoloration of the anterior incisors. We
citrus and hard candy.
also noted loss of enamel on the posterior occlusal
After the patients condition was controlled
and anterior palatal surfaces (Figure 1 and
medically, we suggested a multiphase dental
Figure 2). This patients teeth demonstrated loss
treatment plan, along with a referral to a
of the superficial enamel surface with a smooth
prosthodontist. We first fabricated and delivered
and shiny appearance; depressions or concavities
a nightguard/occlusal splint to establish a new
at the cervical areas of the palatal aspect of the
vertical dimension. The nightguard/occlusal
maxillary anterior teeth; a rising, shiny appearsplint helped protect the teeth against further
ance of an amalgam restoration at the occlusal
gastric erosion and aided in administering topical
aspect of the posterior dentition; and eroded
fluoride gel. The second and third treatment
JADA, Vol. 133, June 2002
Copyright 2002 American Dental Association. All rights reserved.

735

C L I N I C A L

P R A C T I C E

Figure 3. Left bitewing radiograph showing enamel loss

(arrows).

Figure 4. Right bitewing radiograph showing enamel loss

(arrows).

phases were completed at a private dental office following our instructions. In the second phase, temporary acid-etched resin-based composite restorations
were fabricated and were used to re-establish the
vertical dimension and anterior guidance. In the
third and last treatment phase, porcelain-fused-tometal crowns were fabricated and were used to permanently restore the dentition back to form and
function.

possible symptoms associated with dental erosion

included vomiting, experiencing sour taste, belching,
heartburn, stomachache and pain on awakening.
Oral symptoms associated with GERD include
burning mouth syndrome, tooth sensitivity, loss of
the vertical dimension of occlusion and aesthetic disfigurement.12 Ajagbe and colleagues7 reported two
cases of unexplained enamel erosion of the posterior
dentition that they determined to be consistent with
silent GERD.
Two other forms of enamel loss are attrition and
abrasion. Attrition is physiological wearing of the
tooth structure by tooth-to-tooth contact. Abrasion is
pathological wearing of the tooth structure by a
mechanical process such as toothbrush abrasion.12
These two conditions may be confused or associated
with dental erosion, but they usually can be differentiated with a thorough oral examination and patient
history. Eccles and Jenkins13 developed a gradual
grading scale for dental erosion.
If a dentist is suspicious that a patient may have
gastric reflux, the dentist should refer the patient for
further medical evaluation including endoscopic, histologic and manometric examinations to evaluate
sphincter function, peristaltic efficiency, mucosal erosion and swallowing function. Erosive esophagitis,
Barretts syndrome, laryngopharyngitis and lung
abscess are all possible complications. Furthermore,
a sleep laboratory evaluation with polysomnographic
recordings can reveal sleep arousals, oral pH values
of less than 4 and abnormal swallowing frequency.4,16
With regard to dental erosion having a physiological cause, it usually is necessary to manage dental
erosion with a combination of both pharmacotherapeutic and behavioral (for example, diet) strategies.
Viable pharmacotherapeutics that tend to heal ero-

DISCUSSION

Dental erosion may be caused by either behavioral or

physiological etiologies. Behavioral etiologies include
citrus abuse (sucking on citrus fruit or leaving citrus
fruit in contact with tooth enamel for long periods),
bulimia, use of chewable vitamin C tablets and overconsumption of carbonated beverages. Sucking on
citrus fruit or citrus candies may damage teeth by
causing erosion of the labial surfaces of the maxillary
anterior teeth; citrus fruits contain citric acid that
dissolves tooth enamel more readily than other acids
because, in addition to the effect of the acidity, it
forms a complex of calcium citrate.9 The erosion pattern of bulimia is relatively distinctive and consists
of enamel loss primarily of the palatal surfaces of the
maxillary anterior dentition and, in severe cases, of
the buccal surfaces of posterior mandibular teeth.
This pattern is consistent with the anatomical position of the head while vomiting.15 Other behavioral
causes of dental erosion include sucking on hard
candy, consuming sports drinks, using apple vinegar,
eating pickles and working in industrial environments that have high acid contents.1
Physiological etiologies related to dental erosion
include gastric reflux and GERD. With regard to
acid reflux, Jarvinen and colleagues5 reported that
736

JADA, Vol. 133, June 2002

Copyright 2002 American Dental Association. All rights reserved.

C L I N I C A L

P R A C T I C E

dental therapy is necessary to

restore dental form and function.

Dr. Nasr is an associate dean for special projects, Professor of Prosthodontics, Howard University College of Dentistry, Washington.

Dr. Ali was a

resident, Advanced
Education in General
Dentistry, Howard
University College of
Dentistry, Washington,
when this article was
written. Dr. Ali now is a
staff dentist, Dental
Center, Ministry of
Health, Kuwait.

Dr. Brown is an
associate professor,
Departments of Oral
and Maxillofacial
Pathology and Oral
Diagnosis and
Radiology, Howard
University College of
Dentistry, 600 W St.,
N.W., Washington, D.C.
20059, e-mail
rbrown@howard.edu.
Address reprint
requests to Dr. Brown.

Dr. Rodriguez is an
assistant professor,
Department of Restorative Dentistry, Howard
University College of
Dentistry, Washington.

sions include histamine2 blockers

and gastric
secretion
inhibitors, such
as omeprazole.17 These drugs, however, generally are
outside the purview of dentistry and usually are
administered by the patients physician. Behavioral
strategies for treating GERD include having the
patient raise the height of his or her head when
sleeping; avoid particular foods and beverages such
as chocolate, alcohol and caffeine; and avoid meals
close to bedtime.
CONCLUSION

The patient in our case presented with generalized

dental erosion, and he denied having any history of
GERD, bulimia, heartburn or any other gastric
symptoms. We referred the patient to a gastroenterologist for a medical consultation that confirmed a
diagnosis of silent GERD.
Dentists play an important part in the diagnosis
of silent GERD. It is important to resolve the active
medical condition before initiating definitive dental
treatment. After successful medical intervention,

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1997;24(2):102-8.
3. Bartlett DW, Evans DF, Smith BG. The
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4. Gudmundsson K, Kristleifsson G, Theodors A, Holbrook WP. Tooth
erosion, gastroesophageal reflux, and salivary buffer capacity. Oral
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Dr. Moody is the
director, Advanced
Education in General
Dentistry, Howard
University College of
Dentistry, Washington.

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