Acid Reflux
Acid reflux

Also called: GERD, gastroesophageal reflux disease. A digestive disease in which stomach acid or bile irritates the food pipe lining and can result in erosion of tooth enamel. More than 3 million US cases per year. This is a chronic disease that occurs when stomach acid or bile flows into the food pipe and irritates the lining. Acid reflux and heartburn more than twice a week may indicate GERD.

Understanding Acid Reflux and Its Dental Manifestations

Dental professionals commonly review health histories listing medications that identify patients with a diagnosis of acid reflux. Most often, a specialized physician known as a gastroenterologist treats this condition. However, there are dental manifestations, so it is important that dental professionals identify these patients and recommend appropriate dental therapies to protect the long-term health of the dentition. Furthermore, dental professionals have the opportunity to recognize this condition in untreated patients and may need to refer those patients to a physician for further evaluation.

Overview
Evidence indicates that up to 36 percent of otherwise healthy Americans suffer from heartburn at least once a month and that 7 percent experience heartburn as often as once a day. The incidence of GERD increases markedly after the age of 40. Not just adults are affected; even infants and children can have GERD.

GERD is caused by a combination of conditions that increase the presence of acid reflux in the esophagus. Factors that weaken or relax the lower esophageal sphincter make reflux worse are:

  • Lifestyle -- Use of alcohol or cigarettes, obesity, and poor posture (slouching).
  • Medications -- Calcium channel blockers, beta blockers, theophylline (Tedral, Hydrophed, Marax, Quibron), nitrates, and antihistamines.
  • Diet -- Fatty and fried foods, chocolate, garlic and onions, drinks with caffeine, acidic foods such as citrus fruits and tomatoes, spicy foods, and mint flavorings.
  • Eating habits -- Eating large meals and/or eating just before bedtime.
  • Other medical conditions -- Hiatal hernia, pregnancy, diabetes, and rapid weight gain.
  • Dental manifestations:
    Acid reflux is associated with a
    demineralization action resulting in dental enamel erosion (Figure 1).

Dental enamel consists primarily (almost 97 percent by weight) of a calcium phosphate mineral in the form of carbonated hydroxyapatite (CHA). CHA is insoluble in an alkaline medium. However, its solubility increases with a decrease in the oral pH. This effect was first noted as a result of direct contact of the tooth surface with acids from extrinsic sources such as beverages. Unlike dental caries, where the demineralization is caused by an acidic environment in GERD is due to the reflux of hydrochloric acid from the stomach (Figure 2.).

The erroseive effect tends to be locoalized on the palatal aspects of the maxillary teeth. The dental enamel erosion has been documented by profilometric scans, spectrophotometric analysis, and scanning electron microscopy(SEM).

Patients on some weight loss diets and those who consume fruit based drinks are at an increased risk due to the additional extrinsic exposure of acid contained in these diets.

Figure 1. Enamel errosion can be caused when there is a decrease in oral pH.

 

Psychiatric disorders such as bulimia nervosa, where patients eat excessively and then induce vomiting several times, is another intrinsic source of oral acid. The vomiting of gastric content serves as the source of the acid. Salivary function is important in neutralizing the acid refluxing from the stomach and hence reducing its dental erosive effect. Medications that reduce the salivary function contribute to the acid-induced dental erosion problem. These medications include antidepressants, antipsychotic medications, bronchodilators, and diuretics. The progressive steps of erosion as reported by Pontefract are as follows: 

 


Figure 2. The demineralization of calcium hydroxyapatite (a major constituent of enamel) from hydrochloric acid.                                          is an early step in the erosion process.

  • Chalky or “frosted” appearance
  • Smooth, glazed appearance
  • Eroded and thinned enamel with pitted microcracks and a translucent appearance
  • Cupping of cusp edges of posterior teeth
  • Flat occlusal surfaces

Treatment

The goals of treatment are reducing reflux, relieving symptoms, and preventing damage to the esophagus and teeth.

Self-Care at Home

Lifestyle modifications can relieve reflux symptoms. The following steps, if followed, may reduce reflux significantly:

  • Refraining from eating three hours prior to bedtime. This allows the stomach to empty. Without food stimulation, the stomach’s hydrochloric acid production decreases. 
  • Avoiding lying down right after having eaten at any time of day. Elevation of the head six inches off of the bed. Gravity helps prevent reflux.
  • Avoiding the ingestion of large meals. Eating a lot of food at one time increases the amount of acid needed to digest it. The alternative is to eat smaller, more frequent meals throughout the day.
  • Avoiding fatty or greasy foods, chocolate, caffeine, mints or mint-flavored foods, spicy foods, citrus, and tomato-based foods. These foods decrease the competence of the lower esophageal sphincter. 
  • Avoiding alcohol ingestion. Alcohol increases the likelihood of acid reflux.
  • Smoking cessation. Smoking weakens the lower esophageal sphincter and increases reflux.
  • Losing excess weight. Overweight and obese people are much more likely to have bothersome reflux than people of healthy weight. 
  • Standing upright or sitting up straight and maintaining good posture. This helps food and acid pass through the stomach instead of backing up into the esophagus.
  • Discussing with health care provider the intake of certain medications such as over-the-counter pain relievers, including aspirin, ibuprofen (Advil, Motrin), or medicines for osteoporosis. These can aggravate reflux in some people.

Referances: Dentistryiq.com, Authors Vincent W. Yang, M.D., PH.D. Mohammad Wehbi, M.D.

Image/Photo Referance: PEPTEST (www.pwptest.co.uk)