gastroesophageal reflux disease (gerd): a case study

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Original Article
GASTROESOPHAGEAL REFLUX DISEASE (GERD): A CASE STUDY
ABDULAZIZ M ALBAKER
ABSTRACT
Gastroesophageal Reflux Disease (GERD) has different signs and symptom depending on the severity of the disease. One of the early signs is dental erosion. It results from reflux of the gastric contents
into the oral cavity. Dental erosion can cause teeth sensitivity, dental caries, lost vertical dimension
and dental aesthetic problems. To restore the function and the aesthetic of the oral cavity, full mouth
rehabilitation is sometimes indicated. The current case report is about a 45-year-old male who was
diagnosed with GERD resulting in dental erosion. He underwent full mouth rehabilitation.
Key Words: Gastroesophageal Reflux Disease (GERD), dental erosion, gastric reflux, full mouth
rehabilitation.
INTRODUCTION
Gastroesophageal Reflux Disease (GERD) is a
relatively common condition, in which stomach acids
are refluxed up through the esophagus and oral cavity,
causing heartburn in stomach and dental erosion in the
mouth.1,2,3 The condition is defined as the involuntary
passage of gastric contents into the esophagus.4 Symptoms of GERD include pyrosis, heartburn, chest pain,
hoarseness, asthma, recurrent pneumonia, chronic
cough, otitis media, reflux laryngitis, and sore throat.5,6
The most important GERD symptom from the dental
perspective is regurgitation, resulting in transportation
of acidic gastric juices in the mouth following a reflux
episode.7
Dentists are often the first health care professionals to diagnose systemic diseases through observation
of oral manifestations. The GERD patients generally
experience frequent vomiting, heartburn, belching,
pain on awakening, acidic taste, and stomach pain.8
These patients are 31 times more likely to have dental
erosion than others. Risk factors for GERD also include
obesity, hiatal hernia, and pregnancy.9,10
Dental erosion is defined as the progressive loss of
hard dental tissues caused by a chemical process not
involving bacterial action. Dental erosion has been
associated with ingestion of acidic foods, bulimia, rumination and GERD.11 In addition to causing dental
erosion, undiagnosed and/or untreated GERD may also
Dr Abdulaziz AlBaker, Associate Professor, Department of
Prosthetic Dental Sciences, College of Dentistry, King Saud
University, Riyadh, Saudi Arabia. Correspondence: Dr
Abdulaziz AlBaker, PO Box 60169, Riyadh 11545, Kingdom of
Saudi Arabia
Email: [email protected]
Phone: +966-11-4677237
Received for Publication:
April 30, 2016
Accepted after minor revision:
May 28, 2016
result in esophagitis, Barrett’s epithelium, esophageal
adenocarcinoma and aspiration pneumonitis of various
degrees. It is necessary that dentists recognize GERD
so that timely preventive and curative measures can
be instituted.12,13 GERD is one of the most common comorbidities, and a factor associated with exacerbation
in patients with chronic obstructive pulmonary disease
(COPD). Many COPD-related medications (except inhaled anticholinergics) are associated with increased
risk of GERD.14
A survey conducted by the National Heartburn
Alliance in 2000 estimated that 60 million Americans
have GERD symptoms at least once per month, and
25 million adults have daily symptoms.6 A Saudi study
in 2013 reported a GERD prevalence of 45% high compared to that reported in the literature.15 A systematic
review reported a GERD range of 18.1-27.8% in North
America16, 8.8-25.9% in Europe17,18, 2.5-7.8% in East
Asia19, and 8.7-33.1% in the Middle East.20,21
CASE REPORT
A 45 year-old male came to the prosthodontic clinic
of Marquette University College of Dentistry complaining of “short and ugly frontal teeth”. His medical
history revealed GERD since four years. The patient
has been neglecting his teeth due to financial reason,
though brushing his teeth twice a day. There was no
history of dental bruxism. There was also no history of
over- exposure to the etiologic factors associated with
dental erosion such as ingestion of citrus fruits, vinegar
and carbonated drinks. Upon clinical examination,
generalized dental erosions affect mainly occlusal and
buccal surface of posterior teeth and incisal and lingual
surfaces of anterior teeth (Fig 1 & 2).
Pakistan Oral & Dental Journal Vol 36, No. 2 (April-June 2016)
345
Gastroesophageal reflux disease (GERD)
The objective of the dental treatment was to
restore the lost teeth structures caused by the acid
reflux, and ensure optimum dental function and
aesthetic. The first 3 visits were for diagnostic data
collection and analysis. The treatment plan was then
finalized. Full mouth rehabilitation was planned for
the patient.
Before starting the prostheses stage; all carious
teeth (including recurrent caries) were restored with
Filtek™ Supreme Ultra Universal Restorative (3M
Center, St. Paul, MN 55144, USA). All abutment teeth
were thoroughly examined. As some of the teeth did
not have enough remaining coronal tooth structure for
Fig 4: Frontal view photograph of mandibular and
maxillary teeth provisional crowns
Fig 1: Intraoral mandibular occlusal view
photograph showing enamel erosion on the
occlusal and buccal surface
Fig 2: Intraoral maxillary occlusal view photograph
showing enamel erosion on incisal and palatal surfaces
Fig 5: Intraoral Maxillary occlusal view photograph
of the final crowns
Fig 6: Intraoral Mandibular occlusal view
photograph of the final crowns
adequate ferrule effect, crown lengthening surgery was
performed.
A diagnostic wax-up was done to plan the anticipated occlusion and aesthetic outcome. Provisional
crowns for the teeth were manufactured according to
the diagnostic wax-up and index (Fig 3). Provisional crowns and the Fixed Dental Prosthesis (FDPs)
were fabricated using autopolymerized acrylic resin
ALIKE™ (GC 3737 W. 127th Street Alsip, IL 60803,
USA).
Fig 3: Frontal view photograph of mandibular and
maxillary teeth diagnostic wax-up
The provisional crowns remained in the patients’
mouth for one week to test function and aesthetic (Fig
4). A duplicate cast of the provisional crowns were
Pakistan Oral & Dental Journal Vol 36, No. 2 (April-June 2016)
346
Gastroesophageal reflux disease (GERD)
created to be used as a guide in the process of making
final crowns. Final impressions of the prepared teeth
were taken and sent to the dental laboratory to manufacture final prostheses which were metal-ceramic
crowns except the second molars which were all-metal
crowns. The final prostheses received from the dental
laboratory were tried and cemented in the patients’
mouth (Fig 5 & 6).
After the patient felt comfortable with the new
provisional crowns for 3 weeks, impressions of the provisional crowns were made, and casts were poured. Final
impressions were taken of all prepared natural teeth
with polyvinylsiloxane (PVS) impression material (Virtual XD impressions, Ivoclar Vivadent Inc. 175 Pineview
Drive Amherst, NY 14228, USA). Centric relation interocclusal records and preparation against provisional
crowns were made with PVS material, LuxaBite from
DMG America (242 South Dean Street, Englewood, NJ
07631, USA). Master casts were cross mounted against
the casts of the provisional crowns which were used to
guide the fabrication of the final prostheses. One week
after the final crowns were cemented, the patient was
called back to the clinic for re-evaluation. The patient
was satisfied with the treatment and was motivated
to maintain good oral hygiene practices. The patient
was placed on a six month recall schedule.
DISCUSSION
Patients with GERD should be referred for dental consultations and a collaborative management of
associated oral manifestations. Although; attrition,
abrasion and erosion are part of aging process of any
dentition, the wear rates of teeth should be monitored
periodically to evaluate any abnormal tooth wear progression.22 Dietary changes may be beneficial if there are
obvious dietary precipitants (coffee, chocolate or fatty
foods) and, life style changes are warranted to reduce
obesity, smoking or excessive alcohol use if present23
However, lifestyle modifications alone are unlikely to
eliminate the symptoms.
Prevention of further tooth wear is a priority in
GERD patients. It involves local preventive, restorative
and maintenance phases. Erosion of dental enamel in
some cases can progress till the complete loss of the
dental tissue. As there are many possible causes of
enamel erosion, the diagnosis can be often difficult.
The erosion of dental enamel is historically been an
alarm symptom or warning sign and an indication for
early endoscopy to rule out GERD.24
In the present case the patients’ ignorance delayed
the proper medical intervention for four years causing
severe damage to his teeth. Due to strong acidity of
gastric juices the GERD patients are less prone to
dental caries because of the effect of gastric acid on
bacteria.25 Despite the high prevalence of dental enamel
erosion, the etiological factors are not apparent. Intake
of carbonated drinks were not exclusively been reported
to be the plausible extrinsic factor for dental erosion.
However, there is an increased risk which was reported
for developing erosion even if someone consumes less
than one litre of carbonated drink per week.26
Although there is no special mention about voice
problems, earlier studies proved that GERD can cause
serious voice problems and laryngopharyngeal disorders
influencing the patients’ quality of life.27,28 This issue
should be considered during the phonetic test during
the try-in of the final prosthesis.
In this case, the patient never had any previous
restorations, therefore, all aspects related to achieving
optimum dental function and esthetics were considered
before finalizing the treatment plan. The patient did
not complain of specific about heartburn, belching, and
unexplained sour taste. However, it is not necessary
that all the patients with GERD experience all these
symptoms, a condition known as "silent GERD".8
There is a widely held view that gastroesophageal
reflux and its associated symptoms are trivial; leading
very often to suboptimal treatment of these patients.29
Recent data also suggest that every second GERD
patient leaves dissatisfied with his/her treatment.2
However; in this case, the plan for full mouth rehabilitation constructed in consensus with the patient. It
was based on the severity of erosion and his functional
and esthetic needs.25 The diagnostic wax-up and index
helped in teeth preparation and provisional crowns. The
provisional crowns were tested and evaluated for their
esthetics before going for the final prosthesis. Despite
the excellent prognosis of the full mouth rehabilitation,
ignoring the medical management of GERD; and lack
of periodic dental recall visits can affect the longevity
of the prosthodontic treatment.
ACKNOWLEDGEMENT
The author would like to acknowledge the support
received from the staff of Prosthetic Dental Clinic in
completing the treatment successfully. Special thanks
to Mr. Ranan Kamalan for his support in keeping track
of each phase in the publication process.
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