Incisal palatal erosion, the face of reflux
What is Dental Erosion?
Dental erosion (DE) is the loss of dental structure (enamel, dentin or root cementum) due to the action of acids of non-bacterial origin.
The origin of these acids can be intrinsic to the individual (gastric acid) or extrinsic, mainly related to eating habits or drug treatments. These acid agents act by directly degrading the dental surface or temporarily acidifying saliva and subsequently acting on the tooth.
The action of an acid, added to bruxism, aggressive brushing and changes in the protective effect of the salivary biofilm (due to changes in the mineral environment of saliva due to diet or drugs that alter its synthesis at the glandular level, making its protective effect less minor) potentiate, as a whole, the destructuring of both enamel and dentin, causing aesthetic alterations, sensitivity or dental pain and functional alterations of the occlusion.
What is Gastroesophageal Reflux Disease (GERD)?
GERD (Montreal consensus definition) is a condition that develops when reflux of gastric contents causes bothersome symptoms and/or complications (symptomatic and/or erosive) of the esophagus and extraesophagus (oral cavity, larynx, lungs, ear) to the patient.
Relationship between ED and GERD
Systematic reviews of the scientific literature show a statistically significant relationship between ED and GERD. Furthermore, this relationship increases with age [29] and [42].
24% of ED patients have GERD and 32.5% of GERD patients have ED [29].
Between the years 2018 and 2019, Li Yuanyuan et al. presented three publications with a notable impact, both due to the sample size and the applied methodology:
They showed, for the first time, that bruxists with GERD for long periods are more prone to severe tooth wear.
Tooth wear in nocturnal bruxism is the consequence of attrition enhanced by intrinsic acids (erosion) rather than attrition alone.
Areas of dental erosion caused by intrinsic acids have a characteristic distribution. Acid reflux initially attacks the palatal aspect of the upper teeth, especially the upper incisors [31].
On the other hand, it is worth noting the importance of chronic alcohol consumption as an important risk factor in dental erosion [43].
In 88 patients with GERD, dental erosions were found to be more prevalent in patients with frequent respiratory symptoms than in occasional or no respiratory symptoms. Erosion on the palatal surface of the upper incisors was the main manifestation in these patients. Acid reflux is the main cause of dental erosion in patients with GERD and respiratory symptoms [41].
The location of the ED and its specificity can indicate GERD, which can help in its early diagnosis [44].
Considering these data, when dentists detect dental erosion, they may be the first to suspect the diagnosis of GERD, especially in the so-called “silent refluxes” [30].
Importance of GERD
GERD is considered a disease whose incidence increases over the age of 40. In the last decade, the proportion of young adults with GERD has increased, especially those between 30-39 years of age. This study suggests that the proportion of young adults with esophagitis or Barrett’s esophagus (a precancerous lesion of the esophagus) may be increasing [45].
Barrett’s esophagus occurs in 6-14% of people with GERD, and of these Barrett’s patients (with or without GERD), 0.2-0.5% develop esophageal adenocarcinoma (ACE) [32].
60% of people with ACE have had GERD symptoms and there is an association between the frequency and severity of GERD with the increased risk of ACE [33] and [34].
Other authors affirm that more than 50% of the patients with Barrett’s or ACE did not present symptoms of gastroesophageal reflux, despite suffering from it [36].
Some authors warn that endoscopy, as a diagnostic method of GERD, shows high specificity, but low sensitivity for the diagnosis of GERD, since the mucosa is normal in more than 70% of patients with symptomatic GERD [39]. Endoscopy is appropriate only in the presence of warning symptoms such as dysphagia, unintentional weight loss, multiple risk factors for Barrett’s esophagus (>50 years, male, prolonged reflux symptoms, obesity), or inadequate response to antisecretory therapy. [40].
Although a fundamental objective in the early diagnostic examination of ACE is to identify patients with Barrett’s esophagus [37] and [38], the evidence on the effectiveness (benefits and harms) of the diagnostic tests for ACE and precancerous conditions (Barrett and dysplasia) are rare and uncertain, making it difficult to conclude that people with chronic GERD should be screened for ACE and precancerous lesions [35].
These data lead me to a conclusion: if a patient does not present GERD symptoms, but the dental surfaces, especially the non-masticatory (non-masticatory portion of palatal surfaces of upper incisors, lingual of molars) and masticatory (masticatory portion of palatal surfaces of upper incisors, occlusal molars with cusps transformed into deep fossae), presenting evident signs of erosions (smooth surfaces free of stains) it is not enough to recommend a discharge splint. We must assess possible erosions in soft tissues, other extraesophageal manifestations and suspect a GERD characteristic of an asymptomatic patient, refer him to his digestive doctor and… good luck on this path.
We start talking about dental erosion and end up getting into esophageal cancer. The key to not establishing falsely alarming causal relationships will be to pay attention to a good clinical examination and differential diagnosis without losing sight of the family history.