CATEGORY 104 AUSTRALASIAN DENTIST LINICAL Tooth wear and the role of gastric acid Tooth wear is a complex chemical and tribological relationship of friction, wear and lubrication that occurs in the mouth. Erosion is a significant complicating and accelerating factor occurring alone or in conjunction with other forms of wear such as attrition or abrasion. Establishing the aetiology of wear is an important part of case management, allowing patient education and mitigation strategies to slow or stop wear and protect the longevity of teeth and restorations. Dentists can include a risk assessment questionnaire that explores sources of both intrinsic and extrinsic acids, to help identify the aetiology in cases of wear. A link to a useful patient self-assessment is included at the end of this article. Gastric acid Gastric acid is produced by the parietal cells of the stomach lining. The production of gastric acid is controlled by a complex process involving hormones and neural signalling. When food enters the stomach, the hormone gastrin is released into the bloodstream. Gastrin stimulates the parietal cells to produce and secrete hydrochloric acid and other enzymes that aid in digestion. Gastric acids – with a pH of around 1 to 3 – play a significant role in the erosion of teeth, softening and dissolving the mineral content of the tooth enamel and dentine, causing wear with smooth rounded effects on occlusal and buccal surfaces of posterior teeth. If the tongue is involved inmovement over upper anterior teeth, ablation and significant palatal erosion can be observed. By Dr Andrea Shepperson GERD and why we need to pay attention to it Dental professionals may be the first clinicians to detect gastroesophageal disease, in observing dental erosion with no other extrinsic aetiology. Gastroesophageal reflux (GER) is a normal physiologic occurrence. It occurs after meals for approximately one hour, and is mitigated by peristalsis of the oesophagus, mechanical protection of the Lower Oesophageal Sphincter or LES, and the buffering effect of saliva. Acid enters the oesophagus for a short period of time after a meal and the effect is transient. Reflux, also known as gastroesophageal reflux disease (GERD), occurs when stomach acid flows back up into the oesophagus, causing irritation and inflammation. A patient may not present with overt symptoms of reflux, or note it on their medical history form, but may exhibit signs of intrinsic sources of acid and correlating wear patterns. The following patients reported no current history of reflux in their medical history and had none of the classical symptoms of gastroesophageal disease. (Fig. 1, 2) Some common symptoms of reflux include: 1. Heartburn: A burning sensation in the oesophagus or at the lower oesophageal sphincter. It may occur after ingestion of specific foods and drinks. 2. Regurgitation: The sensation of stomach contents coming back up into the mouth or throat. 3. Chest pain: Some people may experience chest pain or discomfort, which can be mistaken for a heart attack. Atypical symptoms may include: 1. Dysphagia: Reflux can cause irritation and swelling in the oesophagus, making it difficult to swallow. 2. Post-nasal drip: A reflex action 3. Asthma, bronchitis, pneumonia, or laryngitis 4. Hoarseness or sore throat: Reflux can irritate the vocal cords, leading to hoarseness or a sore throat. 5. Globus sensation: A feeling of something stuck in the throat. 6. Nausea and vomiting: Reflux can cause nausea and vomiting, especially after meals. 7. Bad breath: Stomach acid can cause bad breath, as well as a sour or bitter taste in the mouth. GERD is exacerbated by intraabdominal pressure and smooth muscle relaxation of the LES. Extrinsic relaxants can cause laxity in the LES. These include medication and dietary factors. Commonly eaten foods will relax the LES – caffeine, alcohol, methylxanthine found in chocolate, garlic and onions and mint. Epidemiologic estimates of the prevalence of GERD are based primarily on the typical symptoms of heartburn and regurgitation. A systematic review found the prevalence of GERD to be 10–20% of the Western world with a lower prevalence in Asia. There is a definite relationship between GERD and obesity. Reflux- type symptoms have been reported ranging from Figure 1: Severe wear in a patient with reflux Figure 2: Digital scans of a patient with a history of sleep disordered breathing and a bad taste in his mouth. Extensive erosion is evident. When questioned further about GERD he reported using antacids.
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