EFFECTS OF PROTON PUMP INHIBITORS ON DENTAL EROSIONS CAUSED BY GASTROESOPHAGEAL REFLUX DISEASE

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1 Odontology EFFECTS OF PROTON PUMP INHIBITORS ON DENTAL EROSIONS CAUSED BY GASTROESOPHAGEAL REFLUX DISEASE Andrei Vasile OLTEANU 1, Dana Elena MITRICĂ 2, Gheorghe Gh. BĂLAN 3, Carmen SAVIN 4, Adriana BĂLAN 4 1 M.D., PhD student, Gr. T.Popa UMPh of Iaşi, Faculty of Medicine 2 M.D., PhD, Gr. T.Popa UMPh of Iaşi, Faculty of Medicine 3 LL.B., M.D., PhD student, Gr. T.Popa UMPh of Iaşi, Faculty of Medicine 4 DMD, PhD, Gr. T.Popa UMPh of Iaşi, Faculty of Dental Medicine Corresponding author: balan.gheo@yahoo.com Abstract Background: Numerous studies worldwide have assessed the association between dental erosions or other related oral manifestations, and the gastroesophageal reflux disease (GERD). Nowadays, one of the main therapeutic resources of GERD is represented by proton pump inhibitors (PPIs). Adequate salivary secretions and flow are considered mandatory for the protection of both teeth and esophageal mucosa. The aim of the present study was to evaluate the possible correlation between GERD treatment options and subsequent control of oral manifestation, taking as premises that either PPIs or dietary and lifestyle changes may control oral patterns of GERD by acting on salivary secretions. Methods: 48 clinically diagnosed GERD adult patients with oral manifestations, mainly erosions, were included in the study, none of which showing alarming symptoms that would require further gastroenterologic examination. Oral examination evaluated the DMF (decayed, missing, filled) and OHI-S (Simplified Oral Hygiene) indices. Salivary flow was evaluated by the Saxon test. 25 patients were prescribed dietary and lifestyle measures and PPIs (omeprazole 20 mg), whereas 23 patients were managed only through dietary and lifestyle modifications. General assessment was performed at the time of diagnosis and 4 weeks afterwards. Results: No significant differences as to the DMF index, OHI-S index or Saxon test were found over the 4 weeks management between the groups. Conclusions: Oral manifestation of GERD may be caused by impaired salivary secretions and flow, otherwise no - positive or negative - effect could be secondary to PPI therapy. Accordingly, complex oral rehabilitation of GERD patients and collaboration between gastroenterologists and dentists should be promoted. Keywords: gastroesophageal reflux, dental erosion, oral manifestations, proton pump inhibitors, diet. 1. INTRODUCTION The common dietary habits of the 21 st century have made gastroesophageal reflux disease (GERD) a common cause for medical gastroenterology assessment and treatment. Richter and associates reported that 25-40% of Americans experience symptomatic GERD at some point; moreover, around 7-10% of Americans experience symptoms of GERD on a daily basis [1]. A typical set of symptoms includes heartburn, regurgitation, and dysphagia [2]. Nevertheless, a minority of patients could suffer from GERD, even in the absence of these symptoms, because abnormal reflux can also cause atypical (extraesophageal) symptoms, such as coughing, chest pain, and wheezing [3]. Epidemiologically, because many individuals try to control symptoms using over-the-counter (OTCs) medication without consulting a medical professional, the actual number of individuals with GERD is probably higher than estimated [4]. Numerous studies, developed worldwide, have assessed the associations between dental erosions or other linked oral manifestations and GERD, because of the impaired salivary ph and flow in GERD patients adequate salivary secretions being considered mandatory for the protection of both teeth and esophageal mucosa [5]. Treatment of GERD involves a stepwise approach starting from lifestyle modification towards control of gastric acid secretion through medical therapy with antiacids or PPIs or surgical treatment with corrective antireflux surgery [6-8]. Improvement of salivary secretions and diminishment of dental manifestations are therefore expected. The aim of the study was to evaluate the possible correlation between various early treatments and management options for GERD and subsequent International Journal of Medical Dentistry 289

2 Andrei Vasile OLTEANU, Dana Elena MITRICĂ, Gheorghe Gh. BĂLAN, Carmen SAVIN, Adriana BĂLAN control of oral manifestations, taking as premises that both conservative management (diet and lifestyle changes) and PPIs may positively influence the disorders regarding salivary secretions, and therefore may be a useful resource in managing the associated oral conditions. 2. MATERIALS AND METHODS In 2005, the American College of Gastroenterology (ACG) published updated guidelines for the diagnosis and treatment of GERD, according to which, for patients with symptoms and history consistent with uncomplicated GERD, the diagnosis of GERD may be assumed only by clinical examination and history talking, and empirical therapy may be initiated [3]. 48 naive clinically diagnosed GERD adult patients with oral manifestations, mainly erosions, were included in the study, none of which showing alarming symptoms (nausea, vomiting, severe regurgitation, weight loss or hemorrhage) that would require further gastroenterology assessment. Oral examination was performed by a trained dentist, alongside clinical examination and history talking performed by a gastroenterologist. Assessment of patients was done in each case in the morning, on an empty stomach, after proper morning dental hygiene. Dental examination evaluated the DMF index (decayed, missing, filled), as described by Cappelli et al. [9], and the OHI-S index (Simplified Oral Hygiene), as described by the Malmo University team [10]. Salivary flow was also evaluated by the Saxon test described by Kohler et al., 1985, patients being measured as to the quantity of salivary secretions after chewing on a folded sterile sponge for 2 min [11]. Proper informed consent for study inclusion was obtained from all patients. Further guideline acknowledged management options [3] were PPIs therapy (omeprazole 20mg PO qd in the morning, 30 min before breakfast, for 4 weeks) and dietary and lifestyle changes, as showed in Table patients were prescribed dietary and lifestyle measures and PPIs Group A, whereas 23 patients were managed only through dietary and lifestyle modifications Group B. General assessment was performed in the same conditions, by the same professionals, at the time of diagnosis and 4 weeks afterwards. Table 1. Dietary and lifestyle changes prescribed in managing GERD Losing weight in all patients with BMI over 25 kg/sqm Avoiding alcohol, chocolate, citrus juice, and tomato-based products, peppermint, coffee and onion Avoiding large meals Waiting 3 hr after a meal before lying down Elevating the head of the bed 30 cm Maintaining proper oral hygiene teeth brushing after meals at least 2 times a day Including at least a daily diet of 2 L liquids Each patient was graded an OHI-S index between 0 and 6, before and after 4 weeks of management trial. Upon DMFT indexes evaluation, each patient was assessed the mean number of decayed, missing or filled teeth over 32 teeth examination, the parameters studied being listed in Table 2. Saxon test values were described for each patient by salivary flow mass. 290 volume 19 Issue 4 October / December 2015 pp

3 EFFECTS OF PROTON PUMP INHIBITORS ON DENTAL EROSIONS CAUSED BY GASTROESOPHAGEAL REFLUX DISEASE Table 2. DMFT parameters definition DMFT: Mean number of decayed, missing or filled teeth % DMFT Percentage of population affected with dental caries Percentage of population with untreated decayed teeth MT Mean number of missing teeth %D MNT Mean number of teeth DT Mean number of decayed teeth %Ed Percentage of edentulous population 3. RESULTS AND DISCUSSION The mean OHI-S index among patients of group A was 4.52 before therapy and 2.92 after therapy, whereas the indexes of group B patients dropped from a mean value of 4.56 before, to 2.91 after dietary and lifestyle management (p < ). Mean DMFT parameters studied over 32 teeth before and after therapy trial are showed in Table 3 for group A and in Table 4 for group B, respectively. As to the salivary flow, the mean Saxon test index dropped from 3.85 g/2 min to 2.73 g/2 min in group A, and from 4.10 g/2 min to 2.85 g/2 min in group B, respectively. Table 3. Mean DMFT parameters for group A Before trial After trial Before trial After trial % DMFT MT 1 1 %D MNT DT 3 3 %Ed Table 4. Mean DMFT parameters for group B Before trial After trial Before trial After trial % DMFT MT 1 1 %D MNT DT 4 4 %Ed As expected, no significant differences were recorded in the DMF index, OHI-S index or Saxon test along the 4 week management between the groups. Otherwise, improvement in OHI-S indexes and Saxon test quantifier inside the same study group before and after management trial was detected. Diet and lifestyle changes seem to be sufficient for limiting and preventing further vitality, aestethics and function loss of the affected teeth. Dietary factors are also thought to be the most important risk factors for dental erosion [12]. Nevertheless, even more significant changes after dietary measures were found in childern by International Journal of Medical Dentistry 291

4 Andrei Vasile OLTEANU, Dana Elena MITRICĂ, Gheorghe Gh. BĂLAN, Carmen SAVIN, Adriana BĂLAN Huang et al., 2014 [13]. On the other hand, prevention of chronic acid regurgitation is mandatory in the management of tooth erosion, and a recent Cochrane review found out that PPIs were the most effective in controling acid reflux [14]. In this respect, another review article stated that the effectiveness of PPIs in relieving regurgitation symptoms in adults was modest and lower than that for heartburn, raising questions on the need for a more effective treatment [15]. Subsequently, another Cochrane review confirmed the more effective relief of symptoms by surgery (laparoscopic Nissen fundoplication) compared with medication therapy [16]. Furthermore, the development of novel techniques for the diagnosis and management of GERD confirms the true complexity of the GERD diagnosis and therapy and as also evidenced in our study the much lower effectiveness of PPIs [17]. Complete cessation of nocturnal acid regurgitation may be difficult to achieve only by pharmacologic treatment [18]. Interestingly however, awareness should be raised on any drugs or medicines consumed by patients that may cause or exacerbate hyposalivation and lead to xerostomia [18]. Tooth erosion is highly unlikely to be caused by alkaline bile juices from duodenogastroesophageal regurgitation (DGER) [19]. 4. CONCLUSIONS Analysis of GERD-associated manifestations in the oral cavity showed that dental erosions, halitosis, oral transient burning sensation, mucosal ulcerations, dysgeusia or loss of taste and both xerostomia and increased salivary flow may be secondary to the acid reflux. Pathogenically, dental erosions and/or cavities of GERD patients appear to be mainly caused by impaired salivary secretions and flow, otherwise no - positive or negative - effect could be secondary to PPI therapy. No statistically significant difference was found between the oral impact of PPIs plus diet and lifestyle changes therapy versus diet and lifestyle changes alone. Therefore, in relationship to the extra-digestive management of GERD patients, diet and lifestyle changes appear as sufficient for controlling oral and dental manifestations. On the other hand, complex oral rehabilitation of GERD patients and collaboration between gastroenterologists and dentists should be promoted. References 1. Herbella FA, Sweet MP, Tedesco P, Nipomnick I, Patti MG. Gastroesophageal reflux disease and obesity. Pathophysiology and implications for treatment. J Gastrointest Surg. 2007; 11(3): Sveen S. Symptom check: is it GERD? J Contin Educ Nurs. 2009; 40(3): DeVault KR, Castell DO. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Am J Gastroenterol. 2005; 100(1): Spechler SJ. Epidemiology and natural history of gastro-oesophageal reflux disease. Digestion. 1992; 51(1): Di Fede O, Di Liberto C, Occhipinti G, Vigneri S, Lo Russo L, Fedele S, Lo Muzio L, Campisi G. Oral manifestations in patients with gastro-oesophageal reflux disease: a single-center case control study. J Oral Pathol Med. 2008; 37(6): Giannini EG, Zentilin P, Dulbecco P, Vigneri S, Scarlata P, Savarino V. Management strategy for patients with gastroesophageal reflux disease: a comparison between empirical treatment with esomeprazole and endoscopy-oriented treatment. Am J Gastroenterol. 2008; 103(2): Katz PO. Medical therapy for gastroesophageal reflux disease in Rev Gastroenterol Disord. 2007; 7(4): Fass R, Sifrim D. Management of heartburn not responding to proton pump inhibitors. Gut. 2009; 58(2): Cappelli DP, Mobley CC. Prevention in Clinical Oral Health Care. Philadelphia: Mosby Elsevier; Greene JC, Vermillion JR. Simplified Oral Hygiene Index [internet] 2015 [cited 2015 Sept] 11. available from: Methods-and-Indices/Oral-Hygiene-Indices/ Simplified-Oral-Hygiene-Index--OHI-S/. 12. Kohler PF, Winter ME. A quantitative test for xerostomia. The Saxon test, an oral equivalent of the Schirmer test. Arthritis Rheum. 1985; 28(10): Wang X, Lussi A. Assessment and management of dental erosion. Dent Clin North Am. 2010; 54(3): Huang LL, Leishman S, Newman B, Seow WK. Association of erosion with timing of detection and 292 volume 19 Issue 4 October / December 2015 pp

5 EFFECTS OF PROTON PUMP INHIBITORS ON DENTAL EROSIONS CAUSED BY GASTROESOPHAGEAL REFLUX DISEASE selected risk factors in primary dentition: a longitudinal study. Int J Paediatr Dent. 2015; 25: Van Pinxteren B, Sigterman KE, Bonis P, Lau J, Numans ME. Short-term treatment with proton pump inhibitors, H2-receptor antagonists and prokinetics for gastro-oesophageal reflux diseaselike symptoms and endoscopy negative reflux disease. Cochrane Database Syst. Rev. 2010; (11): CD Kahrilas PJ, Howden CW, Hughes N. Response of regurgitation to proton pump inhibitor therapy in clinical trials of gastroesophageal reflux disease. Am. J. Gastroenterol. 2011; 106: Wileman SM, McCann S,Grant AM, Krukowski ZH, Bruce J. Medical versus surgical management for gastro-oesophageal reflux disease (GORD) in adults. Cochrane Database Syst. Rev. 2010; (3):CD Sifrim D, Lundell L, Zerbib F. Gastro-oesophageal reflux disease. Best Pract. Res. Clin. Gastroenterol. 2010; 24(6): Ranjitkar S, Kaidonis JA, Smales RJ. Gastroesophageal reflux disease and tooth erosion. Int J Dent. 2012; 2012: Koek GH, Tack J, Sifrim D, Lerut T, Janssens J. The role of acid and duodenal gastroesophageal reflux in symptomatic GERD. Am. J. Gastroenterol. 2001; 96(7): International Journal of Medical Dentistry 293

EXTRAESOPHAGEAL MANIFESTATIONS OF GASTROESOPHAGEAL REFLUX DISEASE WITH IMPLICATIONS FOR ORAL CAVITY

EXTRAESOPHAGEAL MANIFESTATIONS OF GASTROESOPHAGEAL REFLUX DISEASE WITH IMPLICATIONS FOR ORAL CAVITY Crînguţa Paraschiv*, Cristina Gavrilescu, Irina Cotea, Manea Paloma, Rodica Ghiuru Gr. T. Popa" U.M.Ph.