Howden⁶ first reported the association between GERD and dental erosion in 1971. He and others have reported that dental erosion may serve as a diagnostic sign of acid reflux.^6–8 Silent GERD refers to gastric reflux without symptoms such 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

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.

In this article, we present and discuss the case of a patient with dental erosion secondary to silent GERD.

	CASE REPORT

TOP ABSTRACT CASE REPORT DISCUSSION CONCLUSION REFERENCES

 
A 30-year-old man came to the Howard University College of Dentistry’s oral diagnosis clinic with erosion of the occlusal surfaces of his posterior teeth and of the palatal surfaces of his maxillary anterior teeth. His chief complaints were the yellow discoloration of his teeth and the chipping of the incisal edges of his incisors. His medical history was noncontributory. The patient denied having a history of gastrointestinal problems, heartburn or experiencing a sour taste on awakening. He denied any history of bulimia. There was no family history related to gastritis or acid reflux. The patient did admit to drinking lots of fruit juice and eating spicy food.

We evaluated the patient’s occlusion and found a decreased vertical dimension secondary to enamel erosion.

When we clinically examined the patient, we found that he had good oral hygiene, thin translucent enamel, loss of occlusal tooth structure and yellow discoloration of the anterior incisors. We also noted loss of enamel on the posterior occlusal and anterior palatal surfaces (Figure 1 and Figure 2). This patient’s teeth demonstrated loss of the superficial enamel surface with a smooth and shiny appearance; depressions or concavities at the cervical areas of the palatal aspect of the maxillary anterior teeth; a rising, shiny appearance of an amalgam restoration at the occlusal aspect of the posterior dentition; and eroded occlusal tooth surfaces of the cusp tips of the posterior teeth.^12–14 We evaluated the patient’s occlusion both clinically and with mounted study models and found a decreased vertical dimension secondary to enamel erosion. A full-mouth radiographic series and a panoramic radiograph revealed a uniform thinning of the enamel of the occlusal surfaces of the posterior dentition, the lingual surfaces of the maxillary anterior dentition and Class II distal caries of the maxillary right second premolar (Figure 3 and Figure 4).

View larger version (104K): [in this window] [in a new window]   Figure 1. Occlusal view of the maxillary teeth.

View larger version (114K): [in this window] [in a new window]   Figure 2. Occlusal view of the mandibular teeth.

View larger version (124K): [in this window] [in a new window]   Figure 3. Left bitewing radiograph showing enamel loss (arrows).

View larger version (124K): [in this window] [in a new window]   Figure 4. Right bitewing radiograph showing enamel loss (arrows).

After the patient’s condition was controlled medically, we suggested a multiphase dental treatment plan, along with a referral to a prosthodontist. We first fabricated and delivered a nightguard/occlusal splint to establish a new vertical dimension. The nightguard/occlusal splint helped protect the teeth against further gastric erosion and aided in administering topical fluoride gel. The second and third treatment 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-to-metal crowns were fabricated and were used to permanently restore the dentition back to form and function.

	DISCUSSION

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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 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, Barrett’s 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 erosions 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 patient’s 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

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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, dental therapy is necessary to restore dental form and function.

View larger version (144K): [in this window] [in a new window]   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.

View larger version (129K): [in this window] [in a new window]   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{at}howard.edu". Address reprint requests to Dr. Brown.

View larger version (139K): [in this window] [in a new window]   Dr. Rodriguez is an assistant professor, Department of Restorative Dentistry, Howard University College of Dentistry, Washington.

View larger version (87K): [in this window] [in a new window]   Dr. Moody is the director, Advanced Education in General Dentistry, Howard University College of Dentistry, Washington.