Gastroesophageal reflux disease (GERD) is a chronic condition characterized by the reflux of gastric contents into the esophagus, leading to mucosal damage and various extra-esophageal manifestations, including dental erosion. Dental erosion is the progressive loss of dental hard tissue due to chemical processes without bacterial involvement. It is primarily caused by acidic exposure from dietary sources, medications, or intrinsic factors such as GERD [1]. The prevalence of GERD-related dental erosion has been widely studied, with evidence suggesting that the acidic pH of gastric refluxate plays a significant role in demineralizing the enamel and dentin, increasing the risk of tooth surface loss [2].

Patients with GERD often experience frequent episodes of regurgitation, which expose the oral cavity to gastric acids with a pH as low as 1.2. The continuous exposure leads to the dissolution of hydroxyapatite, resulting in irreversible dental erosion, primarily affecting the palatal and occlusal surfaces of teeth [3]. Studies have shown a strong association between GERD severity and the extent of dental erosion, with more severe cases exhibiting higher rates of enamel loss [4]. The presence of dental erosion in GERD patients is often underdiagnosed, as it progresses silently without immediate symptoms, unlike dental caries [5]. Several risk factors influence the severity of dental erosion in GERD patients, including dietary habits, oral hygiene practices, and salivary flow rate. Saliva plays a crucial role in neutralizing acids and promoting remineralization; however, GERD patients often exhibit reduced buffering capacity, exacerbating the erosive process [6]. Additionally, lifestyle factors such as smoking, alcohol consumption, and the use of certain medications (e.g., proton pump inhibitors) may contribute to altered oral pH and increased susceptibility to dental erosion [7].

The impact of GERD-related dental erosion extends beyond aesthetics, affecting mastication, speech, and overall quality of life. Early diagnosis through comprehensive dental and gastroenterological evaluations is essential for preventing progressive tooth structure loss. This study aims to assess the prevalence and severity of dental erosions in GERD patients at a single center, contributing to a better understanding of the relationship between acid reflux and oral health [8].

Study Design and Setting

This study is a hospital-based, cross-sectional observational study.

Study Population

The study included patients diagnosed with gastroesophageal reflux disease (GERD) based on clinical history, endoscopic findings, and/or 24-hour pH monitoring. Patients attending the gastroenterology and dental outpatient departments were screened for participation.

Inclusion Criteria

1. Patients aged 18 years and above.
2. Diagnosed cases of GERD as per the Montreal classification criteria.
3. Patients with at least 10 natural teeth.
4. Willing to provide informed consent.

Exclusion Criteria

1. Patients with other conditions causing dental erosion, such as bulimia nervosa, chronic vomiting disorders, or Sjögren’s syndrome.
2. Individuals with a history of excessive intake of acidic foods/beverages or occupational exposure to acids.
3. Patients with a history of head and neck radiation therapy.
4. Those on medications known to induce xerostomia (e.g., antihistamines, antidepressants).
5. Patients with existing severe periodontal disease or extensive prosthetic rehabilitation.

Sample Size Calculation

The sample size was calculated using the formula for prevalence-based studies:

n=Z2 Pq/ d2 

where:

• Z=1.96Z = 1.96Z=1.96 (for 95% confidence interval)
• P=30%=0.30P = 30\% = 0.30P=30%=0.30 (estimated prevalence)
• d=10%=0.10d = 10\% = 0.10d=10%=0.10 (margin of error)

Substituting these values:

 =80.67

Rounding up, the required sample size is 81.

Data Collection

A structured questionnaire and clinical examination were used for data collection.

1. Patient History and Questionnaire

A detailed history was taken, including:

• GERD symptoms (frequency, severity, duration).
• Medication use (proton pump inhibitors, H2 blockers, antacids).
• Dietary habits, including acidic food and beverage consumption.
• Oral hygiene practices and habits (e.g., toothbrushing technique, frequency).
• Presence of dry mouth symptoms and saliva consistency.

2. Dental Examination

A comprehensive oral examination was performed by a trained dental professional to assess dental erosion using the Basic Erosive Wear Examination (BEWE) index:

• Score 0 – No erosive tooth wear.
• Score 1 – Initial loss of enamel surface texture.
• Score 2 – Distinct lesion with enamel loss and possible dentin involvement.
• Score 3 – Severe tissue loss with dentin involvement.

The affected surfaces (palatal, occlusal, incisal) were noted, and photographs were taken for documentation. The severity of erosion was correlated with GERD severity.

Salivary Analysis

Unstimulated saliva samples were collected in the morning to measure:

• Salivary pH (using a digital pH meter).
• Buffering capacity (using a colorimetric pH test strip).
• Salivary flow rate (stimulated and unstimulated).

Endoscopic and pH Monitoring Correlation

For a subset of patients, esophagogastroduodenoscopy (EGD) and 24-hour pH monitoring data were obtained from hospital records to classify GERD severity and correlate with dental erosion scores.

Statistical Analysis

Data were analyzed using SPSS. Continuous variables (age, BEWE scores, salivary pH) were expressed as mean ± standard deviation (SD) and compared using the Student’s t-test or ANOVA. Categorical variables (GERD severity, presence of erosion) were analyzed using the chi-square test. Pearson’s correlation was used to assess relationships between GERD severity and dental erosion scores. A p-value < 0.05 was considered

Table 1. Demographic and Clinical Characteristics of the Study Population

Interpretation:

The study included 81 patients diagnosed with GERD. The mean age was 44.6 years, with 55.6% males and 44.4% females. About 35.8% were smokers, and 33.3% reported alcohol consumption. The majority (72.8%) were on proton pump inhibitors (PPI) or H2 blockers for GERD management.

Table 2. Prevalence and Severity of Dental Erosion in GERD Patients

Interpretation:

Dental erosion was present in all GERD patients. 32.1% had mild erosion, 44.4% had moderate erosion, and 23.5% had severe erosion. This suggests a strong association between GERD and different degrees of enamel loss.

Table 3. Relationship Between GERD Severity and Dental Erosion

                 (*Statistically significant, p<0.05)

Interpretation:

Patients with severe GERD had significantly higher BEWE scores (mean 3.2) compared to those with mild GERD (1.7). The p-value <0.001 indicates a statistically significant correlation between GERD severity and dental erosion.

Table  4. Correlation Between Salivary pH and Dental Erosion

                   (*Statistically significant, p<0.05)

Interpretation:

Salivary pH was significantly lower in patients with more severe dental erosion (p < 0.05). Those with highly acidic saliva (pH < 5.5) had the highest BEWE scores (mean 3.5), indicating a direct relationship between salivary acidity and dental erosion severity.

Gastroesophageal reflux disease (GERD) is a common chronic condition characterized by the reflux of gastric contents into the esophagus, leading to mucosal damage and several extra-esophageal manifestations, including dental erosion. The findings of this study suggest a significant association between GERD severity and the extent of dental erosion in affected patients, which aligns with previous studies indicating the damaging effect of acidic refluxate on dental structures [9]. In our study, 81 patients with GERD were evaluated for dental erosion, with 32.1% showing mild erosion, 44.4% moderate erosion, and 23.5% severe erosion, demonstrating the varying degrees of dental damage in this population. These findings support the evidence that GERD contributes significantly to dental enamel degradation [10].

The pathophysiological mechanism underlying dental erosion in GERD patients is primarily attributed to the frequent regurgitation of acidic gastric contents into the oral cavity, exposing teeth to gastric acid with a pH as low as 1.2, resulting in the dissolution of hydroxyapatite and enamel loss [11]. Our study found a statistically significant correlation between GERD severity and the extent of dental erosion. Patients with severe GERD exhibited the most substantial enamel loss, with a mean BEWE score of 3.2. This result is consistent with previous research demonstrating that severe GERD is often associated with higher rates of dental erosion [12, 13]. The relationship between GERD and dental erosion may be due to the frequent, prolonged exposure of teeth to gastric acid, especially in patients who regurgitate large volumes of acidic material.

Salivary pH has been implicated in the severity of dental erosion in GERD patients. In this study, salivary pH was significantly lower in patients with more severe dental erosion, with those having pH < 5.5 showing the highest BEWE scores. This is in agreement with studies that report a reduced salivary buffering capacity in GERD patients, which exacerbates the erosive process by failing to neutralize the acids effectively [14, 15]. Additionally, the salivary flow rate may be compromised in GERD patients, further contributing to a diminished ability to protect the teeth from acid-induced damage.

It is essential to note that lifestyle factors, such as smoking and alcohol consumption, are commonly present in GERD patients and may further increase the risk of dental erosion. In our study, 35.8% of the participants were smokers, and 33.3% consumed alcohol. Previous studies have shown that both smoking and alcohol can lower the salivary pH, increase acid reflux episodes, and thus contribute to an enhanced risk of dental erosion [16]. Furthermore, medications like proton pump inhibitors (PPI), which are frequently prescribed to GERD patients, have been associated with reduced salivary flow and altered oral pH, potentially exacerbating the erosive process [17].

The clinical impact of GERD-related dental erosion is not only aesthetic but also functional. It can impair mastication, speech, and overall oral health quality. As dental erosion progresses, it can lead to tooth sensitivity, increased susceptibility to cavities, and more severe damage to the dental structure, which underscores the need for early identification and management [18]. Regular dental assessments and timely interventions in GERD patients can help mitigate these risks and improve patient quality of life.

The study emphasizes the need for increased awareness among healthcare professionals about the oral manifestations of GERD, particularly dental erosion. A multidisciplinary approach involving gastroenterologists and dentists is critical in preventing and managing this complication effectively. Further longitudinal studies are warranted to explore the long-term outcomes of GERD-related dental erosion and to identify optimal preventive strategies.

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