Gastric reflux

As dentists we are trained to look for the signs of gastric reflux as they are reflected in the oral cavity but our knowledge of their causes and management is lacking. Our medical colleagues are well versed in the diagnosis, causes and management but their knowledge and screening of dental effects is lacking. This represents one of many areas where the bridge between the two professions can be improved immensely.

-Acid erosion is reflected in the mouth as progressive loss of mineralised tooth structure. Loss of surface texture (perikymata) and smooth, shiny enamel is a good sign that there has been acid erosion in the past
-Thinning of enamel allows dentine lobes to show through more obviously. If you can see the shadowy texture of dentine through the enamel there has already been irreversible tooth loss.
-Scratches into enamel in various patterns either horizontally or randomly are a sign that the patient has a habit of brushing their teeth after an acid attack
-Erosion from gastric reflux typically presents as erosion to the palatal surfaces of the upper incisors. This is because the stomach contents rise up and over the tongue and collide with the upper incisors on the way out of the mouth. typically the lower teeth are protected by the tongue and pool of saliva. -Nocturnal reflux will also show erosions on the palatal surface of the upper molars as the acid will tend to pool on one side of the mouth. The buccal surfaces are usually protected by parotid saliva.
-Extrinsic erosion will have a more labial inclination and severe erosions can be seen on patients who suck on lemons. These tend to be older patients but this is not always the case.
-The 6s act sort of like an archeological artefact as they are often the oldest grinding teeth in the adult mouth. Occlusal cupping on the 6s should prompt you to ask about a history of acid intake and gastrix reflux. if no habits have changed then you may expect the same damage to occur to the remaining teeth.
-A chronic reflux patient will have the tell tale sign of constant clearing of the throat or coughing due to the irritation of the esophageal mucosa.
-Gastrix reflux is often associated with obstructive sleep apnoea due to the increased intrathoracic pressure during the apnoeic events.
-A reflux patient may complain of heartburn or chest pain especially after a meal. However, many patients do not report these symptoms probably because they think it is a normal state. These symptoms will be worse in the supine position. Some clinicians trial omeprazole for 2 weeks and if patients notice an improvement in their symptoms then this is diagnostic of gastrix reflux.
-Reflux can leave an acidic or bitter taste in the mouth
-Gastroesophageal reflux disease (GERD) occurs when there is leakage of the stomach contents through the lower esophageal sphincter
-GERD can be caused by a hiatal hernia especially in obesity and pregnancy where the upper stomach herniates through the diaphragmatic hiatus. These can be asymptomatic but severe cases may require surgical correction.
-Contributing factors to GERD include dietary (Fatty foods, coffee, alcohol, chocolate, peppermint), cigarette smoking, obesity, pregnancy

-Endoscopy is an important diagnostic procedure in chronic GERD sufferers as long term acid secretion can lead to malignant changes to the esophageal lining.

-Treatment generally involves

1.  Avoidance of lifestyle factors that aggravate GERD. Smoking, alcohol and dietary factors
2. Avoidance of acidic foods and drinks which can irritate the lining of the esophagus and increase stomach acidity. 
3. Weight loss
4. Decreasing meal portions 
5. Eating more than a few hours before bed time or lying down to allow stomach acidity and volume to decrease before entering the supine position
6. Elevating the head of the bed or sleeping in an elevated position with a specially designed wedge allows gravity to reduce the leakage through the lower esophageal sphincter.
7. OTC antacids or prescription medications e.g PPIs or H2 blockers
8. Surgery