The study investigates the oral manifestations of gastroesophageal reflux disease (GERD), highlighting its increased prevalence and associated complications such as dental erosion, xerostomia, and oral mucosal changes. Conducted over several months at a dental college in Ahmedabad, the case-control study included 120 participants, revealing a significant occurrence of oral symptoms in GERD patients compared to controls. Findings indicate that while GERD and dental erosions lacked significant correlation, other oral manifestations were notably prevalent in GERD patients, emphasizing the need for dentists to recognize these signs for timely intervention.

1. Oral Manifestations in
Patients with
Gastro-Esophageal
Reflux Disease: A
Hospital-Based
Case-Control Study
Limdiwala PG, Shah JS, Parikh SJ, Pillai JP. Oral manifestations in patients with
gastro-esophageal reflux disease: A hospital-based case-control study. J Indian Acad Oral
Med Radiol 2023;35:56-60

2. Introduction
• In medical practice, gastroesophageal
reflux disease (GERD) is one of the
most common disorders with
increased prevalence in recent times.
• It is a chronic condition characterized
by a retrograde flow of gastric
contents into the esophagus or
adjacent organs, resulting in various
symptoms, with or without tissue
damage

3. Multi-factorial Etiologies
• Increase in age, impaired lower oesophageal sphincter function,
and delayed gastric emptying,
• Anatomical & oesophageal mucosal integrity disruption,
• A decrease in oesophageal peristalsis,
• Disruption of the esophagogastric junction,
• Systemic diseases and drugs lead to decreased salivary secretion
and pH and thus peptic ulcer disease and reflux esophagitis

4. • Along with dental erosion, GERD has complications such as
esophagitis, peptic ulcer disease, adenocarcinoma of gastric
mucosa, and aspiration pneumonia.
• In routine practices, dentists come across oral mucosal changes in
terms of xerostomia, mucosal ulceration, dental erosion, loss of
taste, halitosis, and non-specific burning sensation.
• In such scenarios, dental practitioners have the vision to
recognize GERD timely, so preventive and treatment measures
can be instituted.

5. Aim & Objective
• The study aimed to analyze the occurrence and correlation
of oral manifestations of patients affected by GERD,
especially with dental erosion.

6. Material & method
• The present case-control study was conducted at a
government dental college and hospital, Ahmedabad, from
march to November 2016.
• Study had been approved by the institutional ethics
committee (iecgdch/5.20/2015;03/02/2016), and
• All the procedures have been performed as per the ethical
guidelines laid down by the declaration of Helsinki (2014).

7. Inclusion criteria
• Include all patients above the age of 20
years
• Patients who were on NSAIDS for
more than 3 months because of any
systemic condition
• Patients who had typical complaints of
GERD such as heartburn/acid burn,
nausea, vomiting/acid regurgitation,
abdominal pain/discomfort, abdominal
distension or fullness, dysphagia,
hiccups/belching, and feeling of salty
sensations in the mouth.
Exclusion criteria
• Patients below the age of 20
years
• Patients who were on certain
medications except for NSAIDs
• Patients who had psychological
problems
• Patients with abnormal attrition
and tooth abrasion

8. • Informed written consent was taken for participation in the study
• A total of 120 participants were randomly selected
Sixty (group 2; 32 males, 28
females) healthy individuals were
selected without any symptoms or
medical history of GERD or any
other gastrointestinal diseases.
Sixty (group 1, 42 males and 18
females) patients were
diagnosed by
gastroenterologists

9. • Group 1 patients were diagnosed by gastroenterologists
through proper history, clinical pictures, and necessary
investigations such as 24 h pH meter, USG, endoscopy,
and H. Pylori infection on gastric and duodenal biopsies.
• Group 2 healthy individuals selected without any
symptoms or medical history of GERD or any other
gastrointestinal diseases or any treatment taken for the
same before.

10. Assessment of oral
manifestations
• Xerostomia was assessed by clinical history using a
standardized questionnaire developed by Field et al.
• Oral features such as xerostomia, erythema on soft/hard palate
or uvula, halitosis/gingivitis, mucosal ulceration/erosion,
burning pain on the tongue or atrophic glossitis, taste alteration,
potentially malignant oral disorders (leukoplakia, OSMF, or
tobacco quid lesion), candidiasis, and dentinal hypersensitivity
were evaluated in both groups.

11. • Dental erosion was
recorded with Eccles and
Jenkins Erosion Grading
Scale
• The detailed case history
sheet was formulated, and
clinical features of
mentioned lesions were
diagnosed and recorded. Gastro Esophageal Reflux Disease (GERD) & Tooth Erosion-
dental news .com

12. Statistical analysis
• All data were analyzed using the IBM SPSS software
package, version 20.0. (Armonk, NewYork: IBM Corp).
• The Chi-square test and continuous variables were
compared by the Mann– Whitney test and the Kruskal–
Wallis test(P < 0.05, significant).

13. Results
• The study consists of 60 GERD-affected (group I) and 60 control
(group II) individuals.
• 31.7% of the total subjects were not having any complaints, and 16.7%
had more than four complaints.

15. The Kruskal–Wallis non-parametric test was performed on the
distribution of the gastric complaints between both groups and
revealed no significant difference in all the variables

16. Discussion
• Literature review shows that heartburn is the most common
complaint with a prevalence of 72–99% and regurgitation with
a prevalence of 33–86%.
• The present study group I showed the importance of heartburn
(40%) followed by nausea, vomiting, and regurgitation
(36.7%) as the classical symptoms with the highest intensity
and frequency having 70% of the subjects with more than three
gastric complaints.

17. • In the present study group, males were predominantly found to
be affected and the age group most affected was 41–50 years.
• Lifestyle factors such as smoking, alcohol, coffee, and chocolate
cause inappropriate relaxation of the lower esophageal sphincter.
• Fatty foods also delay gastric emptying, which may lead to
GERD
• In the present study, 53.3% were non-vegetarians and 71.6%
were smokers, tobacco chewers, and alcoholics, and those
factors showed a strong association with GERD.

18. • In healthy subjects, acid taken into the mouth is usually buffered
within a few minutes.
• Saliva is considered one of the major protective mechanisms of
esophageal mucosa against gastric reflux, and abnormalities have
been linked to GERD pathogenesis, dental health, and dental
erosion.
• The occurrence of xerostomia in patients with GERD was 60%
and 23.3% in the study group and control group, respectively

19. • A retrospective analysis by Watanabe et al. identified a
significant association of GERD with dysphagia, xerostomia,
oral ulceration, gingivitis, and oral inflammation in buccal
mucosa and tongue.
• In another study, ulceration was observed in 60% of the
subjects, especially in the soft and hard palate.
• Studies by Ranjitkar et al and Picos et al also proved that
oral mucosal changes are quite common in GERD patients.

20. • The PMDs were observed in around 57% of GERD patients.
• In a study by Warsi et al, nearly 43% of the subjects had GI
complaints, with a positive association between OSMF and
GERD.
• Study presented dental erosion in 80% (group I) and 22% (group
II) individuals among them.
• Grade I dental erosion according to Eccles and Jenkins Erosion
Grading Scale was found the most.

21. • The prevalence of dental erosions, especially on the lingual
and palatal tooth surfaces, is increased in patients with
GERD, which is supported by several studies.

22. Conclusion
• GERD and dental erosions had no significant correlation, It
may be concluded that patients with GERD may be at risk
for the development of dental erosion.
• Whereas other oral manifestations and mucosal changes
were found significant with GERD

23. CROSS-REFERENCE

24. 1-Risk of Periodontitis in Patients with
Gastroesophageal Reflux
Disease: A Nationwide Retrospective
Cohort Study
Li, X.; Chaouhan, H.S.;Wang, Y.-M.; Wang, I.-K.; Lin, C.-
L.;Shen, T.-C.; Li, C.-Y.; Sun, K.-T. Risk of Periodontitis in
Patients with Gastroesophageal Reflux Disease:A Nationwide
Retrospective Cohort Study. Biomedicines 2022, 10, 2980.

25. Aim and objective -The present study aimed to use
a retrospective cohort study design to clarify the
association between GERD and the subsequent risk
of periodontitis.
Methods -The risk of periodontitis in patients with
GERD was investigated by analyzing
epidemiological data from the Taiwan National
Health Insurance Research Database from 2008 to
2018. They selected 20,125 participants with a
minimum age of 40 years in the GERD group and
non-GERD. The incidence of periodontitis was
determined at the end of 2018.

26. • Results - The overall incidence rate of
periodontitis risk was 1.38-fold higher in patients
with GERD than in those without GERD. After
stratified analyses for sex, age, and comorbidity,
patients with GERD had a higher risk of
periodontitis for age 40–54 years and,
• Conclusions - Results revealed that patients with
GERD have a higher risk of periodontitis
development than those without GERD.

27. 2-Risk factors associated with oral
manifestations and oral health impact of
gastro-oesophageal reflux disease: a
multicentre, cross-sectional study in
Pakistan
Warsi I, Ahmed J, Younus A, et al. Risk factors
associated with oral manifestations and oral health
impact of gastrooesophageal reflux disease: a
multicentre, cross-sectional study in Pakistan. BMJ
Open 2019;9:e021458.

28. Aim and objective-
(1) to identify oral soft and hard-tissue changes
in patients with GORD and
(2) to evaluate these oral changes as indices for
assessing GORD and its severity.
Material & method - In total, 187 patients
underwent esophageal–gastro–duodenoscopy and
had GORD were included in the study. Patients
with GORD were divided according to the
presence of dental erosion into
• group A (with dental erosion, chronic/severe
GORD) and
• group B (without dental erosion, mild GORD).

29. • Patients who were unconscious and had extremely
limited mouth openings were excluded.
• Abnormal conditions and lesions of the oral
mucosa were recorded.
• The impact of oral hard and soft-tissue changes on
the oral health-related quality of life was assessed
using the Pakistani (Urdu) version of the validated
Oral Health Impact Profile-14 (OHIP-14)
instrument
Results – Oral submucous fibrosis (66.3%), ulceration
(59.4%), and xerostomia (47.6%) were significantly
more common in group A.

30. • The prevalence of GORD was 26.7%, within which
the prevalence of DE was 35.3%.
• Unhealthy dietary patterns, nausea/vomiting,
oesophagitis, xerostomia, ulceration, gingivitis, and
angular cheilitis showed a statistically significant
association with chronic GORD and dental erosion.
Conclusion - Patients with GORD and dental erosion
presented with more severe oral manifestations than
those with GORD and no dental erosion. Thus, timely
dental checkups are recommended to assess the
severity of the both systemic and oral disease.

31. 3- Oral soft tissue disorders are associated
with gastroesophageal reflux disease: a
retrospective study
Watanabe M, Nakatani E, Yoshikawa H, Kanno T, Nariai Y,
Yoshino A, Vieth M, Kinoshita Y, Sekine J. Oral soft tissue
disorders are associated with gastroesophageal reflux disease:
retrospective study. BMC gastroenterology. 2017 Dec;17(1):1-0.

32. Aim and objective - The study aimed to investigate
the association OSTDs and GERD
Methods - GERD patients (105 cases), older and
younger controls (25 cases each) were
retrospectively examined for oral symptoms, salivary
flow volume, swallowing function (repetitive saliva
swallowing test ), teeth (DMF indices), and soft
tissues (as evaluation of OSTDs, gingivitis; papillary,
marginal, and attached gingival indexes, OHIS, and
inflammatory oral mucosal regions).
• Clinical histories, which included BMI, alcohol
and tobacco use, and bruxism, were also
investigated.

33. Result - The most common oral symptom in GERD
patients was oral dryness.
• Salivary flow volume and swallowing function in
the GERD patients were significantly lower than
in either of the controls.
• Inflammatory oral mucosal regions were found
only in GERD patients.
• The DMF indices, as a measure of dental caries, in
the GERD patients were higher than in the
younger controls.

34. • Though no significant differences in BMI, the
existence of alcohol and tobacco use were
found, and bruxism, as an exacerbation factor
of periodontal disease, in the GERD patients
was significantly more frequent than in either
control group
Conclusions: OSTDs were associated with
GERD, which was similar to the association
between DE and GERD.

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