Spectrum of dental manifestations of GERD and approaches to their verification

Gastroesophageal reflux disease (GERD) ranges among the most common diseases in therapeutic practice. In addition to the classic complaints, patients often experience extraesophageal symptoms, which can complicate the diagnosis of GERD and require a multidisciplinary approach to the patient management with the assistance of related specialists. These include dental manifestations of GERD, which can be conveniently classified into lesions affecting the soft tissues (vermillion border of the lips, tunica mucosa of mouth, tongue, periodontal tissues) and the dental hard tissues (enamel and dentin) in the oral cavity. Epidemiological data on the prevalence of these or other dental manifestations of GERD are limited and heterogeneous. The article considers a number of pathogenetic factors that explain the cause-and-effect relationship between oral/dental lesions and GERD, including the direct damaging effects of aggressive refluxate molecules, changes in the physicochemical properties of saliva expressed as a decrease in its buffering capacity, reduction in secretion of mucin, growth factors, and antimicrobial peptides, and bruxism. From a practical perspective, it is quite difficult to find a link between GERD and possible dental manifestations due to the heterogeneity and nonspecificity of the latter. If GERD is suspected in patients with oral and/or dental lesions, it is reasonable to use the GERDQ questionnaire, esophagogastroduodenoscopy, and, in some cases, 24or 48-hour pH-impedance measurements and high-resolution manometry. The salivary pepsin and bile acid tests may be used as a potential screening tool to identify a cohort of individuals requiring further examination.

1. Ivashkin VT, Trukhmanov AS, Maev IV, Drapkina OM, Livzan MA, Martynov AI et al. Diagnosis and Treatment of Gastroesophageal Reflux Disease (Clinical Guidelines of the Russian Gastroenterological Association, Russian Scientific Medical Society of Internal Medicine, Russian Society for the Prevention of Noncommunicable Diseases, Scientific Сommunity for Human Microbiome Research). Russian Journal of Gastroenterology, Hepatology, Coloproctology. 2024;34(5):111–135. (In Russ.) https://doi.org/10.22416/1382-4376-2024-34-5-111-135.

2. Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R. The Montreal definition and classification of gastroesophageal reflux disease: a global evidencebased consensus. Am J Gastroenterol. 2006;101(8):1900–1943. https://doi.org/10.1111/j.1572-0241.2006.00630.x.

3. Watanabe M, Nakatani E, Yoshikawa H, Kanno T, Nariai Y, Yoshino A et al. Oral soft tissue disorders are associated with gastroesophageal reflux disease: retrospective study. BMC Gastroenterol. 2017;17(1):92. https://doi.org/10.1186/s12876-017-0650-5.

4. Mahajan R, Kulkarni R, Stoopler ET. Gastroesophageal reflux disease and oral health: A narrative review. Spec Care Dentist. 2022;42(6):555–564. https://doi.org/10.1111/scd.12726.

5. Storr M, Meining A, Allescher HD. Pathophysiology and pharmacological treatment of gastroesophageal reflux disease. Dig Dis. 2000;18(2):93–102. https://doi.org/10.1159/000016970.

6. Di Fede O, Di Liberto C, Occhipinti G, Vigneri S, Lo Russo L, Fedele S et al. Oral manifestations in patients with gastro-oesophageal reflux disease: a single-center case-control study. J Oral Pathol Med. 2008;37(6):336–340. https://doi.org/10.1111/j.1600-0714.2008.00646.x.

7. Pace F, Pallotta S, Tonini M, Vakil N, Bianchi Porro G. Systematic review: gastrooesophageal reflux disease and dental lesions. Aliment Pharmacol Ther. 2008;27(12):1179–1186. https://doi.org/10.1111/j.1365-2036.2008.03694.x.

8. Dundar A, Sengun A. Dental approach to erosive tooth wear in gastroesophageal reflux disease. Afr Health Sci. 2014;14(2):481–486. https://doi.org/10.4314/ahs.v14i2.28.

9. Roesch-Ramos L, Roesch-Dietlen F, Remes-Troche JM, Romero-Sierra G, Mata-Tovar Cde J, Azamar-Jácome AA et al. Dental erosion, an extraesophageal manifestation of gastroesophageal reflux disease. The experience of a center for digestive physiology in Southeastern Mexico. Rev Esp Enferm Dig. 2014;106(2):92–97. https://doi.org/10.4321/s1130-01082014000200004.

10. Li W, Liu J, Chen S, Wang Y, Zhang Z. Prevalence of dental erosion among people with gastroesophageal reflux disease in China. J Prosthet Dent. 2017;117(1):48–54. https://doi.org/10.1016/j.prosdent.2016.04.029.

11. Picos A, Badea ME, Dumitrascu DL. Dental erosion in gastro-esophageal reflux disease. A systematic review. Clujul Med. 2018;91(4):387–390. https://doi.org/10.15386/cjmed-1017.

12. Yanushevich OO, Maev IV, Krikheli NI, Andreev DN, Lyamina SV, Sokolov FS et al. Prevalence and Risk of Dental Erosion in Patients with Gastroesophageal Reflux Disease: A Meta-Analysis. Dent J. 2022;10(7):126. https://doi.org/10.3390/dj10070126.

13. Helle K, Árok AZ, Ollé G, Antal M, Rosztóczy A. Dental evaluation is helpful in the differentiation of functional heartburn and gastroesophageal reflux disease. World J Gastroenterol. 2023;29(31):4774–4782. https://doi.org/10.3748/wjg.v29.i31.4774.

14. Mengatto CM, Dalberto Cda S, Scheeren B, Barros SG. Association between sleep bruxism and gastroesophageal reflux disease. J Prosthet Dent. 2013;110(5):349–355. https://doi.org/10.1016/j.prosdent.2013.05.002.

15. Rabinovich IM, Rabinovich OF, Abramova ES, Denisova MA. Clinical and pathogenetic aspects of various forms of cheilitis. Stomatologiya. 2016;95(1):67–72. (In Russ.) https://doi.org/10.17116/stomat201695167-72.

16. Kislig K, Wilder-Smith CH, Bornstein MM, Lussi A, Seemann R. Halitosis and tongue coating in patients with erosive gastroesophageal reflux disease versus nonerosive gastroesophageal reflux disease. Clin Oral Investig. 2013;17(1):159–165. https://doi.org/10.1007/s00784-012-0705-5.

17. Bodecker CF. Dental erosion: its possible causes and treatment. Dental Cosmos. 1933;75:1056–1062.

18. Picos A, Chisnoiu A, Dumitrasc DL. Dental erosion in patients with gastroesophageal reflux disease. Adv Clin Exp Med. 2013;22(3):303–307. Available at: https://pubmed.ncbi.nlm.nih.gov/23828670.

19. Boyapati R, Vudathaneni VKP, Nadella SB, Bollepalli AC, Marella Y, Adurty C. Reflex Gastroesophageal Disorders and Functional Dyspepsia: Potential Confounding Variables for the Progression of Chronic Periodontitis: A Clinical Study. Int J Prev Med. 2020;11:138. https://doi.org/10.4103/ijpvm.IJPVM_141_19.

20. Locke GR 3rd, Talley NJ, Fett SL, Zinsmeister AR, Melton LJ 3rd. Risk factors associated with symptoms of gastroesophageal reflux. Am J Med. 1999;106(6):642–649. https://doi.org/10.1016/s0002-9343(99)00121-7.

21. Song JY, Kim HH, Cho EJ, Kim TY. The relationship between gastroesophageal reflux disease and chronic periodontitis. Gut Liver. 2014;8(1):35–40. https://doi.org/10.5009/gnl.2014.8.1.35.

22. Li Y, Yu F, Niu L, Hu W, Long Y, Tay FR et al. Associations among Bruxism, Gastroesophageal Reflux Disease, and Tooth Wear. J Clin Med. 2018;7(11):417. https://doi.org/10.3390/jcm7110417.

23. Nota A, Pittari L, Paggi M, Abati S, Tecco S. Correlation between Bruxism and Gastroesophageal Reflux Disorder and Their Effects on Tooth Wear. A Systematic Review. J Clin Med. 2022;11(4):1107. https://doi.org/10.3390/jcm11041107.

24. Tokiwa O, Park BK, Takezawa Y, Takahashi Y, Sasaguri K, Sato S. Relationship of tooth grinding pattern during sleep bruxism and dental status. Cranio. 2008;26(4):287–293. https://doi.org/10.1179/crn.2008.039.

25. Li Y, Fang M, Niu L, Fan Y, Liu Y, Long Y et al. Associations among gastroesophageal reflux disease, mental disorders, sleep and chronic temporomandibular disorder: a case-control study. CMAJ. 2019;191(33):E909–E915. https://doi.org/10.1503/cmaj.181535.

26. Vinesh E, Masthan K, Kumar MS, Jeyapriya SM, Babu A, Thinakaran M. A Clinicopathologic Study of Oral Changes in Gastroesophageal Reflux Disease, Gastritis, and Ulcerative Colitis. J Contemp Dent Pract. 2016;17(11):943–947. https://doi.org/10.5005/jp-journals-10024-1959.

27. Ranjitkar S, Smales RJ, Kaidonis JA. Oral manifestations of gastroesophageal reflux disease. J Gastroenterol Hepatol. 2012;27(1):21–27. https://doi.org/10.1111/j.1440-1746.2011.06945.x.

28. Jiang S, Zheng L, Miao Z. Gastroesophageal reflux disease and oral symptoms: A two-sample Mendelian randomization study. Front Genet. 2023;13:1061550. https://doi.org/10.3389/fgene.2022.1061550.

29. Dawes C, Wong DTW. Role of Saliva and Salivary Diagnostics in the Advancement of Oral Health. J Dent Res. 2019;98(2):133–141. https://doi.org/10.1177/0022034518816961.

30. Dawood IM, El-Samarrai SK. Saliva and Oral Health. Int J Adv Res Biol Sci. 2018;5(7):1–45. https://doi.org/10.22192/ijarbs.2018.05.07.001.

31. Bilbilova EZ. Dietary Factors, Salivary Parameters, and Dental Caries, Dental Caries. IntechOpen, London, UK; 2020.

32. Ziganshina EE, Sagitov II, Akhmetova RF, Saleeva GT, Kiassov AP, Gogoleva NE et al. Comparison of the Microbiota and Inorganic Anion Content in the Saliva of Patients with Gastroesophageal Reflux Disease and Gastroesophageal Reflux Disease-Free Individuals. Biomed Res Int. 2020;2020:2681791. https://doi.org/10.1155/2020/2681791.

33. Sarosiek J, McCallum RW. What role do salivary inorganic components play in health and disease of the esophageal mucosa? Digestion. 1995;(Suppl. 1):24–31. https://doi.org/10.1159/000201298.

34. Yoshikawa H, Furuta K, Ueno M, Egawa M, Yoshino A, Kondo S et al. Oral symptoms including dental erosion in gastroesophageal reflux disease are associated with decreased salivary flow volume and swallowing function. J Gastroenterol. 2012;47(4):412–420. https://doi.org/10.1007/s00535-011-0515-6.

35. Bechir F, Pacurar M, Tohati A, Bataga SM. Comparative Study of Salivary pH, Buffer Capacity, and Flow in Patients with and without Gastroesophageal Reflux Disease. Int J Environ Res Public Health. 2021;19(1):201. https://doi.org/10.3390/ijerph19010201.

36. Koeda M, Tanabe T, Kitasako Y, Momma E, Hoshikawa Y, Hoshino S et al. Saliva secretion is reduced in proton pump inhibitor-responsive nonerosive reflux disease patients. Esophagus. 2021;18(4):900–907. https://doi.org/10.1007/s10388-021-00845-x.

37. Puscas I, Coltau M, Baican M, Domuta G. Omeprazole has a dual mechanism of action: it inhibits both H(+)K(+)ATPase and gastric mucosa carbonic anhydrase enzyme in humans (in vitro and in vivo experiments). J Pharmacol Exp Ther. 1999;290(2):530–534. Available at: https://pubmed.ncbi.nlm.nih.gov/10411559.

38. Shin JM, Sachs G. Pharmacology of proton pump inhibitors. Curr Gastroenterol Rep. 2008;10(6):528–534. https://doi.org/10.1007/s11894-008-0098-4.

39. Jones R, Junghard O, Dent J, Vakil N, Halling K, Wernersson B et al. Development of the GerdQ, a tool for the diagnosis and management of gastro-oesophageal reflux disease in primary care. Aliment Pharmacol Ther. 2009;30(10):1030–1038. https://doi.org/10.1111/j.1365-2036.2009.04142.x.

40. Gyawali CP, Kahrilas PJ, Savarino E, Zerbib F, Mion F, Smout AJPM et al. Modern diagnosis of GERD: the Lyon Consensus. Gut. 2018;67(7):1351–1362. https://doi.org/10.1136/gutjnl-2017-314722.

41. Shetler KP, Bikhtii S, Triadafilopoulos G. Ineffective esophageal motility: clinical, manometric, and outcome characteristics in patients with and without abnormal esophageal acid exposure. Dis Esophagus. 2017;30(6):1–8. https://doi.org/10.1093/dote/dox012.

42. Savarino E, Bredenoord AJ, Fox M, Pandolfino JE, Roman S, Gyawali CP. Advances in the physiological assessment and diagnosis of GERD. Nat Rev Gastroenterol Hepatol. 2018;15(5):323. https://doi.org/10.1038/nrgastro.2018.32.

43. Gyawali CP, Yadlapati R, Fass R, Katzka D, Pandolfino J, Savarino E et al. Updates to the modern diagnosis of GERD: Lyon consensus 2.0. Gut. 2024;73(2):361–371. https://doi.org/10.1136/gutjnl-2023-330616.

44. Yadlapati R, Gyawali CP, Pandolfino JE. AGA Clinical Practice Update on the Personalized Approach to the Evaluation and Management of GERD: Expert Review. Clin Gastroenterol Hepatol. 2022;20(5):984–994. https://doi.org/10.1016/j.cgh.2022.01.025.

45. Li C, Cao X, Wang H. Pathogenesis of pepsin-induced gastroesophageal reflux disease with advanced diagnostic tools and therapeutic implications. Front Med. 2025;12:1516335. https://doi.org/10.3389/fmed.2025.1516335.

46. Race C, Chowdry J, Russell JM, Corfe BM, Riley SA. Studies of salivary pepsin in patients with gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2019;49(9):1173–1180. https://doi.org/10.1111/apt.15138.

47. Du X, Wang F, Hu Z, Wu J, Wang Z, Yan C et al. The diagnostic value of pepsin detection in saliva for gastro-esophageal reflux disease: a preliminary study from China. BMC Gastroenterol. 2017;17(1):107. https://doi.org/10.1186/s12876-017-0667-9.

48. Woodland P, Singendonk MMJ, Ooi J, Nikaki K, Wong T, Lee C et al. Measurement of Salivary Pepsin to Detect Gastroesophageal Reflux Disease Is Not Ready for Clinical Application. Clin Gastroenterol Hepatol. 2019;17(3):563–565. https://doi.org/10.1016/j.cgh.2018.05.016.

49. Rajab YS, Zaidan TF. Evaluation of Salivary Pepsin Levels and Dental Erosion in Patients With Gastroesophageal Reflux Disease. Cureus. 2023;15(2):e34744. https://doi.org/10.7759/cureus.34744.

50. Saritas Yuksel E, Hong SK, Strugala V, Slaughter JC, Goutte M, Garrett CG et al. Rapid salivary pepsin test: blinded assessment of test performance in gastroesophageal reflux disease. Laryngoscope. 2012;122(6):1312–1316. https://doi.org/10.1002/lary.23252.

51. Zhang M, Wu T, Tan N, Chen S, Zhuang Q, Luo Y, Xiao Y. Clinical relevance of salivary pepsin detection in diagnosing gastroesophageal reflux disease subtypes. Gastroenterol Rep. 2023;11:goad053. https://doi.org/10.1093/gastro/goad053.