CATEGORY AUSTRALASIAN DENTIST 105 LINICAL 20-40% in a cohort of white males/females in the USA to 3.5% in a Korean population1,2. Nineteen percent of the Korean population sample reported at least one of the atypical symptoms; chest pain, dysphagia, globus sensation, asthma, bronchitis, pneumonia, or hoarseness. Classifying reflux The Montreal Classification was developed in 2006 by an international group of gastroenterologists to categorize gastroesophageal reflux disease (GERD)3. It includes three categories: a. Oesophageal manifestations: This category includes the classic symptoms of GERD, such as heartburn, regurgitation, anddifficulty swallowing. b. Extra-oesophageal manifestations: This category includes symptoms that occur outside of the oesophagus, such as chronic cough, hoarseness, asthma, and dental erosion. c. Complications: This category includes any complications that may arise from long-term untreated GERD, such as oesophageal strictures or Barrett’s oesophagus. Each of these categories is further divided into subcategories, based on the severity of the symptoms or the presence of other factors. For example, subcategories for erosive esophagitis, non-erosive reflux disease (NERD), Barrett’s oesophagus and laryngopharyngeal reflux (LPR) exist. Patients who suffer from nocturnal or silent GERD are more susceptible to dental damage. Gravity is a helpful physical counter to reflux when a patient is upright. However, when supine and/or during sleep, acid can migrate to the proximal extent of the oesophagus and pool in the oropharyngeal area and around posterior teeth. Acid reaching the mouth can readily remove saliva and the protective protein pellicle, exposing teeth to hydrochloric acid with a pHof 1.5-3.5. Excessive regurgitation, when combined with reduced salivary flow, can cause significant damage to teeth. Why Is LPR Important for dentists? LPR is categorized under the extraoesophageal reflux (EER) category, which includes reflux of gastric contents into the larynx, pharynx, and respiratory tract. It often occurs without traditional symptoms of heartburn and oesophageal irritation. It can be mis-diagnosed by a dentist as perimyolisis associated with an eating disorder. The Montreal Classification defines LPR as “a syndrome characterized by the presence of symptoms and/or signs of laryngeal and pharyngeal mucosal injury attributable to the retrograde flow of gastric contents into the upper aerodigestive tract.” The diagnosis of LPR is based on a combination of symptoms, laryngoscopy findings, and response to treatment. Symptoms of LPR may include hoarseness, chronic cough, throat clearing, postnasal drip, and a sensation of a lump in the throat as well as palatal wear on upper anterior teeth. Laryngoscopy may reveal findings such as erythema (redness) and oedema (swelling) of the larynx and pharynx, granulomas, or vocal cord nodules. Treatment for LPR may involve lifestyle modifications, such as avoiding trigger foods and beverages, and medications to reduce acid reflux and protect the larynx and pharynx from damage. Anti-anxiety medication is used for patients who wake with an acute episode and sensation of choking. The proximal extent of reflux in LPR will impact teeth in 2 ways: 1. Creating an acute episode of a feeling of globus whichmay result in self-induced vomiting to clear a perceived blockage. 2. Acid pooling in the oro-pharyngeal area, creating acid erosion of teeth. Testing For Reflux: What to do if you suspect dental erosion is caused by GERD? The gold standard for testing for reflux is the 24-hour oesophageal pH monitoring test. This test measures the pH (acidity) of the oesophagus over a 24-hour period to determine the frequency and duration of acid reflux episodes. It requires a referral to a gastroenterologist who will gather a careful history and determine if 24-hour monitoring is warranted. During the test, a small tube is inserted through the nose and into the oesophagus. The tube is attached to a device that measures the pH of the oesophagus (Fig. 5). The patient then goes about their normal daily activities, keeping a diary of their symptoms and activities during the test period. The pH monitoring test is the most accurate way to diagnose acid reflux, as it provides a continuous measurement of the pH in the oesophagus over an extended period. Data is downloaded after 24 hours, providing detailed information about the frequency and duration of reflux episodes, as well as the severity of the reflux and proximal extent (Fig. 6). Figure 4: Patient with acute LPR, waking at night to induce vomiting to clear a choking feeling. Figure 5: 24-hour pH impedance testing. Figure 3: Loss of occlusal enamel in a patient of 22 with no symptoms of reflux. 24 -hour pH monitoring confirmed episodes of reflux at night. Figure 6: Waveform report for patient in Figure 3.
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