Oral Health Effects of Gastroesophageal Diseases
Gastroesophageal reflux disease (GERD) affects up to 50% of adults in the Western world, making it one of the most prevalent diseases in the population. GERD is a condition where stomach acid is allowed to flow freely to the esophagus due to the relaxation of the lower esophageal sphincter (LES) over time. The LES is located at the bottom of the esophagus and relaxes to allow the passage of food and liquid into the stomach. After the nutrients have passed through the esophagus, the LES should close. However, in patients with GERD, the LES remains relaxed and allows for stomach acid to flow into the esophagus and potentially into the oral cavity. This exchange of acid is called acid reflux.
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The most common symptom of GERD is heartburn, or inflammation and irritation of the esophagus. Patients with heartburn may seek treatment sooner due to the discomfort, which may reduce the potential for long-term permanent damage. Patients may not realize that some symptoms are related to GERD—such as chronic cough, noncardiac chest pain, and even asthma—which may delay treatment.
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A comorbidity of chronic GERD, dental erosion is a sign that can be noted during routine dental hygiene treatment. Dental erosion is when part of the tooth structure, typically the enamel, is lost due to a chemical (nonbacterial) process. The eroded portion of the tooth appears yellow and shiny, may have rounded cusps and cupping of occlusal surfaces, and restorations appear to be above the level of other tooth structures. In patients with GERD, this chemical process is related to the additional acid entering the oral cavity by the relaxation of the upper and lower esophageal sphincters.
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The salivary flow of patients with GERD is often reduced and, therefore, has a lower buffering capacity when compared to patients without gastrointestinal diseases. Saliva plays a large role in neutralizing the pH of the oral cavity and cleansing the oral structures to help reduce oral diseases, such as dental caries. Knowing this, it is safe to hypothesize that those patients with free-flowing intestinal acids with low acidic pH (often 1.2 or lower) would benefit from an adequate volume of neutralizing saliva. Unfortunately, the opposite is true and, instead, these patients are almost twice as likely to experience xerostomia, even when considering age and saliva composition.
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Affecting anywhere between 25% and 65% of the United States population, xerostomia is typically linked to coated tongue, dry mouth, and hard/soft tissue diseases. However, oral malodor is also linked to systemic disorders, including GERD and laryngopharyngeal reflux (LPR). In healthy individuals, intestinal acids and their corresponding odors remain in the gastrointestinal tract. However, in those with GERD and/or LPR, these acids, odors, and sometimes even bacteria can enter the oral cavity and cause malodor.
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Oral Health Considerations
Once GERD/LPR is identified, it is important to discuss with the supervising dentist and, together, educate the patient on the findings and possible remedies that fall under the dental hygiene scope of practice. Nonpharmaceutical treatments for GERD and LPR can include lifestyle and dietary modifications. Losing weight and reducing or eliminating tobacco and alcohol use can help to improve or eliminate reflux. Dietary modifications are also important in the treatment of reflux. Oral health professionals can educate patients on the most common aggravators of reflux symptoms including the consumption of caffeine, carbonated beverages, wine, fat, tomatoes, and chocolate, as well as late-night eating. It can be difficult to make so many dietary changes at one time. Patients may want to start by decreasing the frequency of harmful foods as well as combining their consumption with main meals. The goal is to successfully decrease the amount of these foods and also limit the amount of time they are in contact with the teeth.