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ORIGINAL ARTICLE
Year : 2018  |  Volume : 36  |  Issue : 2  |  Page : 125-129
 

Oral manifestations of gastroesophageal reflux disease in children: A preliminary observational study


Department of Pedodontics and Preventive Dentistry, Ragas Dental College and Hospital, Chennai, Tamil Nadu, India

Date of Web Publication2-Jul-2018

Correspondence Address:
Kothimbakkam Sai Sarath Kumar
26/51, Sundaramoorthy Vinayagar Koil Street, Triplicane, Chennai - 600 005, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JISPPD.JISPPD_1182_17

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   Abstract 


Aims: This study aimed to document the prevalence of oral manifestations seen among pediatric gastroesophageal reflux disease (GERD) patients in Chennai, Tamil Nadu, India. Methodology: This study was performed at various children's hospitals in Chennai. Fifty-one GERD patients who were assessed by endoscopy and 24 h pH-metry, 31 (60.78%) males and 20 (39.21%) females, aged 2–12 years (mean age, 7.43 years), comprised the study group. All patients answered a detailed frequency questionnaire related to regurgitation and acidic foods and participated in a clinical dental examination. Statistical Analysis Used: Data were analyzed using the SPSS statistical software package version 19. Results: Among the GERD patients, 42 (82.35%) had dental erosion. A total of 668 (57.98%) deciduous teeth and 484 (42.02%) permanent teeth were examined, of which dental erosion was detected in 248 (21.52%) and 171 (14.84%) teeth, respectively. The most commonly affected primary tooth was the occlusal surface of the maxillary posteriors and commonly affected permanent tooth was occlusal surface of the mandibular molars. Conclusions: There may be a positive correlation between GERD and dental erosion. According to this study, presence of erosion, especially in posterior teeth, could be a key to diagnose GERD and refer the child to the gastroenterologist.


Keywords: Children, dental erosion, gastroesophageal reflux disease, posterior teeth


How to cite this article:
Sarath Kumar KS, Mungara J, Venumbaka NR, Vijayakumar P, Karunakaran D. Oral manifestations of gastroesophageal reflux disease in children: A preliminary observational study. J Indian Soc Pedod Prev Dent 2018;36:125-9

How to cite this URL:
Sarath Kumar KS, Mungara J, Venumbaka NR, Vijayakumar P, Karunakaran D. Oral manifestations of gastroesophageal reflux disease in children: A preliminary observational study. J Indian Soc Pedod Prev Dent [serial online] 2018 [cited 2019 Sep 21];36:125-9. Available from: http://www.jisppd.com/text.asp?2018/36/2/125/235675





   Introduction Top


William Osler described “mouth as the mirror of general health,” as oral examination can reveal signs and symptoms of systemic diseases, especially mucocutaneous, immunologic disorders, endocrinopathies, hematologic conditions, systemic infections, and nutritional problems.[1]

Association between alterations in the oral cavity and systemic health has been widely proven.[2],[3] In particular, oral cavity being a part of gastrointestinal system, oral disorders can be an expression of gastrointestinal disease. Children are prone to alterations within the oral cavity, especially in gastrointestinal disorders such as celiac disease, gastroesophageal reflux disease (GERD), or inflammatory bowel disease.[4] GERD is a relatively common condition in infants and children.[5],[6]

GERD is defined as the involuntary passage of gastric contents into the esophagus and known to occur when there is failure of the lower esophageal sphincter to provide a barrier between the esophagus and the stomach.[7] A global definition and classification of GERD has been developed by the Montreal consensus group, based on several evidence-based statements on the characteristics of GERD as “a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications.”[8] In adults, according to systematic reviews, the prevalence of GERD has been reported to range from 10% to 20% in Western countries, whereas lower prevalence rates have been found in Asia, including Japan.[9],[10],[11] Few data are available on the prevalence of GERD in the pediatric population and the incidence was age dependent.[12]

Clinical features of GERD vary in children of different ages.[13] Heartburn and regurgitation are the characteristic symptoms of typical reflux syndrome.[8] Extraesophageal manifestations include laryngeal (reflux laryngitis, hoarseness, chronic cough, vocal cord ulcer, and granuloma), pharyngeal (mucositis), respiratory (asthma, bronchitis, chronic cough, and aspiration pneumonia), and ENT problems (sinusitis and otitis media).[14],[15],[16],[17] In addition, undiagnosed and untreated GERD may also result in Barrett's esophagus and esophageal adenocarcinoma.[18]

The most commonly described oral manifestation attributed to GERD is tooth erosion, which has been widely investigated and reported in dental literature.[19],[20],[21] Since the large number of persons with undiagnosed GERD are “silent refluxers,”[22],[23] dentists may be the first to suspect the presence of this condition from their observations of otherwise unexplained dental erosion.[24] Other manifestations include acidic taste, dysgeusia, burning sensation, halitosis, water brash, and erythema of palatal mucosa and uvula.[25],[26] Caries experience is also higher;[27] colonization of salivary yeast and Mutans streptococci was found to be significantly higher in GERD patients.[28]

The diagnosis begins with a detailed medical history which includes other clinical symptoms, associated disorders, and family history followed by a thorough clinical examination. Twenty-four-hour esophageal pH monitoring is considered the golden standard of GERD diagnosis;[29] endoscopy is also useful for histologic confirmation.[7]

Knowledge about the type of oral pathologies most commonly associated with GERD is essential to provide a helpful guide for both pediatricians and dentists. Considering the high frequency of alterations that can arise in the oral cavity of children suffering from GERD, the dentist should be able to detect the oral manifestations which can be clues to diagnose GERD. Therefore, this study aimed to document the prevalence of oral and dental manifestations seen among pediatric GERD patients in Chennai, Tamil Nadu, India.


   Methodology Top


This study was approved by the institutional ethical committee and signed informed consent was obtained from each parent. Children for the study group were randomly selected from children attending the gastroenterology department at various children's hospitals in Chennai. All children selected had definitive, confirmed diagnosis of GERD using 24-h pH metry and endoscopy. Fifty-one (31 males and 20 females) patients were selected who consented for dental examination. A detailed medical and dental history and details about oral hygiene habits were obtained from the parents prior to the dental examination. Details of each child's diet were recorded and analyzed to eliminate the possibility of dietary causes for the erosion.

The dental examinations were performed by one of the authors using dental mirrors and explorers under daylight. Oral hygiene status was recorded using the Simplified Oral Hygiene Index,[30] caries was charted using the WHO criteria,[31] and presence of erosion and its degree was recorded using Eccles and Jenkins index.[32] The oral soft tissues were examined and abnormalities were noted. The results were recorded on standardized data forms and statistically analyzed.


   Results Top


Demography

Fifty-one study children were examined, among which 31 (60.78%) were male and 20 (39.21%) were female. Their mean age was 7.43 years, ranged from 24 months to 12 years.

Oral hygiene status

According to the Simplified Oral Hygiene Index, among the study children, 9 (17.65%) had good oral hygiene, 12 (23.53%) had fair, and 30 (58.82%) had poor oral hygiene [Figure 1].
Figure 1: Interpretation of the Simplified Oral Hygiene Index of gastroesophageal reflux disease children

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Prevalence of erosion

Among the study population, dental erosion was seen in 42 (82.35%) children. Nearly 21.52% of the primary teeth (248/668) were affected and 14.84% of the permanent teeth (171/484) were affected [Figure 2]. The most commonly affected primary teeth were the maxillary posteriors, especially in the palatal surface, and the least affected was the labial surface of the maxillary anteriors [Figure 3]. Whereas, in the permanent teeth, the most commonly affected teeth were the mandibular molars, especially in their occlusal surfaces, and maxillary premolars showed the least involvement [Figure 4]. There were a greater number of teeth with Grade II and Grade III erosion.
Figure 2: Prevalence of dental erosion in gastroesophageal reflux disease children

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Figure 3: Prevalence of erosion in the primary dentition

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Figure 4: Prevalence of erosion in the permanent dentition

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Prevalence of caries

When the total number of decayed, missing, or filled (dmft/DMFT) teeth was examined, the maximum deft score was 13 and DMFT score was 9.

Prevalence of soft-tissue lesions

Two (3.9%) GERD patients had soft-tissue erythema, especially in the soft palate and uvula.


   Discussion Top


Gastroesophageal reflux is a physiologic event which allows movement of gastric content into the esophagus and oropharynx through relaxation of the lower esophageal sphincter; gastroesophageal reflux becomes pathologic if symptoms or complications are present, in which case the term GERD is used.[33] In spite of its common occurrence, there is little reported in the literature on the oral findings of GERD children.[34]

This study's results showed that GERD children had more dental erosion, which presumably was directed related to the reflux. The prevalence of 82.35% of GERD children showing dental erosion in the present study was higher than reported by O'Sullivan et al. (17%),[35] Meurman et al. (23.93%),[36] and Linnett et al. (46%),[27] but similar to that of Aine et al. (87%)[37] and Ersin et al. (76%).[28] The difference in results among the studies may be due to differences in age and sample sizes.

Both primary and permanent teeth may be affected.[38] In the present study, primary teeth were affected more. This is not surprising as the enamel is less mineralized and thinner in primary teeth and are more prone to acid erosion.[39] The palatal surfaces of the maxillary deciduous posteriors were affected more because the pattern of erosion caused by intrinsic acid may be modulated by the protective influence of the tongue, which forces regurgitated acid over the tongue, along the palate and into the buccal vestibule.[40] Moreover, the typical distribution of dental erosion due to acid reflux involves the lingual surfaces of maxillary teeth.[41] The least affected were the facial surfaces of the maxillary anteriors since patients exposed to extrinsic acids suffer more damage to the labial surface of the upper anteriors, with severity decreasing posteriorly.[40] Among the permanent teeth, mandibular molars were affected more and maxillary premolars were least involved. This is due to the sequence of eruption of the permanent teeth and relative lengths of time the teeth were exposed to gastric acid. However, it has been reported that the cause of dental erosion cannot be reliably identified by the location of the lesions, and that any tooth can be involved depending on the movements of the tongue, cheek, and lips.[42]

To date, there is little information on the caries experience of GERD children. Linnett et al. found that GERD children have more dental caries.[27] In the present study, the prevalence of caries was higher in both dentitions, which was similar to the study conducted by Ersin et al.[28] Second, the caries experience in children with GERD may be due to the fact that they have more enamel hypoplasia.[43] In fact, 58.82% of the study children had poor oral hygiene, which can be also attributed to increased caries activity.

Future research in this area is needed to assess the extent to which oral pH is changed during reflux episodes and the oral modifying factors in the erosion process, particularly in regard to the role of saliva.


   Conclusions Top


This current observation, in which the oral findings of GERD were investigated, clearly demonstrates that children with GERD are at an increased risk of developing erosion and dental erosion, especially in the posterior teeth, which can be a key to diagnose GERD and refer the child to the gastroenterologist. Thus, collaboration between the pediatric gastroenterologist and pediatric dentist during the management of patients with GERD is strongly advocated. In addition, further investigation into strategies for the prevention of the various deleterious oral effects of GERD is urgently required.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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