Type of the Paper (Article Journal of Baghdad College of Dentistry, Vol. 35, No. 2 (2023), ISSN (P): 1817-1869, ISSN (E): 2311-5270 1 Research Article Tooth wear in relation to physical salivary character- istics among gastroesophageal reflux disease Marwa Siddik Abdulrazak 1*, Alhan Ahmed Qasim 2, Ali Ismael Falih3 1. Master student. Department of Pedodontics and Preventive Dentistry. College of Dentistry. University of Baghdad. Baghdad-Iraq. 2. Assistant Professor. Department of Pedodontics and Preventive Dentistry. College of Dentistry. Uni- versity of Baghdad. Baghdad-Iraq. 3. Gastroenterologist at Iraqi health ministry. Arabic Board in Gastroenterology and Hepatology, Bagh- dad-Iraq. *Correspondence :email, marwa.siddik92@gmail.com Abstract: Background: Gastroesophageal reflux disease, is a quite prevalent gastrointes- tinal disease, among which gastric content (excluding the air) returns into the oral cavity. Many 0ral manifestations related t0 this disease include tooth wear, dental caries also changes in salivary flow rate and pH. This study was conducted among gastroesophageal reflux dis- ease patients in order to assess tooth wear in relation to salivary flow rate and pH among these patients and the effect of gastroesophageal reflux disease duration on this relation. Ma- terials and methods: One hundred patients participate in this cross-sectional study for both genders and having an age range of 20-40 years old, patients had been endoscopically identi- fied as having gastroesophageal reflux disease using the classification of Los Angeles (LA), who were attending the Gastroenterology and Hepatology Teaching Hospital in Baghdad. and divided into two groups: group A with grade severity mucosal breakage not longer than 5 mm and Group B with grade severity mucosal breakage more than 5 mm long, Smith and Knight (1984) tooth wear index criteria were used for the assessment of tooth wear. For meas- urement of salivary flow rate and pH, saliva sample (unstimulated) had been collected. Re- sults: Of the entire sample (90%) were having tooth wear. Tooth wear was higher in grade B severity than in grade A severity among patients with gastroesophageal reflux disease dura- tion of two years or less, while it was higher in grade A than in grade B among patients with a duration of more than two years but all these results were statistically non-significant. Sali- vary flow rate and pH showed a non-significant reduction with increasing gastroesophageal reflux disease severity for both of groups concerning disease duration. The correlation of total tooth wear with salivary flow rate and pH was a significantly weak negative correlation in grade A, while a nonsignificant weak negative correlation in grade B. Conclusions: The find- ings of the present study concluded that patients with gastroesophageal reflux disease rec- orded a high occurrence of tooth wear and there was a negative correlation of tooth wear with salivary flow rate and pH among patients with gastroesophageal reflux disease. Keywords: gastroesophageal reflux disease, GERD, tooth wear, salivary flow rate, pH. Introduction Diagnosing many systemic diseases by observation of their oral manifestation possibly makes the dentist the primary health care professional to diagnose such diseases. Gastroesophageal reflux disease (GERD) could be one of such disease, which could be evidenced by the observation of an unexplained presence of tooth wear (dental erosion) (1, 2). The return 0f stomach contents 0ther than air 0r the esophagus is known as gastroesophageal reflux. The term "gastroesophageal reflux disease" (GERD) refers to reflux that causes a variety of symptoms and, or damages or impairs the mucosa of the esophagus or neighboring upper aerodigestive system organs and occasionally the lower respiratory tract(3). Received date: 14-03-2022 Accepted date: 21-04-2022 Published date: 15-06-2023 Copyright: © 2022 by the authors. The article is published under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/li censes/by/4.0/). https://doi.org/10.26477/ jbcd.v35i2.3392 mailto:marwa.siddik92@gmail.com https://orcid.org/0009-0000-3790-6664 https://orcid.org/0000-0003-0682-664X https://creativecommons.org/licenses/by/4.0/ https://creativecommons.org/licenses/by/4.0/ https://doi.org/10.26477/jbcd.v35i2.3392 https://doi.org/10.26477/jbcd.v35i2.3392 J. Bagh. Coll. Dent. Vol. 35, No. 2. 2023 Abdulrazak et al 2 The effects of gastroesophageal reflux disease are not just restricted to the esophagus, but have also frequently been linked to several extra-esophageal involvements (4). Heartburn, regurgitation and Dysphagia represent the classical GERD symptoms (5, 6). In contrast, extra-esophageal symptoms of GERD might include a broad spectrum of illnesses such as nocardiac chest pain, posterior laryngitis, chronic coughing, recurrent pneumonitis, asthma, tooth erosion, and sleeping disorder (7). Dental erosion, dental caries, halitosis, a burning sensation, xerostomia, and erythemia of the uvula and palatal mucosae could be the most frequent oral manifestations of GERD (8). Long durations of gastroesophageal reflux disease have been related to an elevated risk of GERD physical complications which could include local esophageal complications, extraesophageal complications, asthma and even esophageal adenocarcinoma (9). Tooth wear, also known as tooth surface loss, represent the pathological tooth tissue loss caused by a disease process differs from dental caries (10, 11). It occurs as a result of the three processes (attrition, abrasion, and erosion) interaction that can occur, each one alone or in combination (12). Tooth wear etiology is mostly multifactorial as a result of local, systemic, mechanical, biological, chemical and\or tribological factors (13- 15). Evidence suggests that tooth wear is a frequently reported extra-oesophageal symptom of GERD (16). Saliva can be defined as the biologically produced, watery secretions of the salivary glands found in both human and animal oral cavities (17). Several functions were served by human saliva including moistening and lubrication, digestion, taste and smell, wound healing factors, protection of the oral and esophageal mucosa and tooth protection (18). Multiple studies found that there was a significant association between GERD, reduction in salivary flow rate and the subjective “dry mouth” sensation (xerostomia) (19, 20). When compared with controls, Salivary flow rate and pH were found to be lowered among GERD patients (21). As soon as there was no previous Iraqi study on the effect of GERD on oral health, this study was conducted in order to assess tooth wear in relation to salivary flow rate and pH among those patients, the null hypotheses was that there is no relationship between the occurrence of tooth wear and reduced salivary flow rate and pH in patients that having gastroesophageal reflux disease. Materials and Methods After receiving official approval from the College of Dentistry- University of Baghdad's Research Ethics Committee, this cross-sectional study was conducted. It was carried out during the period from the end of March 2021 until the end of September 2021. A pre-study consent form was assigned to all the patients who participated in this study. 100 subjects with gastroesophageal reflux disease (GERD), including both genders and with an age range of 20 to 40 years old, make up the study sample. According t0 the Los Angeles (LA) classification, which divides GERD into 4 grades depending 0n the severity and extent of mucosal breakage, the patients were classified by the specialist (a gastroenterologist) as having any grade of GERD (labeled A through D). the first grade is (A) which denotes one or more mucosal breakage that their length are not exceeding 5 mm and not continuous between the peaks of two or more mucosal folds, the second grade is (B) that denotes there is one or more breakage and their length is more than 5 mm and not continuous between the peaks of two or more mucosal folds, and the third grade is (C) which denotes that breakages are continuous between the peaks of two or more mucosal folds but less than 75% of the circumference of esophageal mucosa will be involved, and the last grade is (D) which J. Bagh. Coll. Dent. Vol. 35, No. 2. 2023 Abdulrazak et al 3 denotes that the involvement of at least 75% of esophageal circumference may be affected by mucosal breakage (9). During the study, only patients with grades A and B (54 patients (54%) and 46 patients (46%), respectively, met the inclusion and exclusion criteria for this study were found. All patients who attend Baghdad's Gastroenterology and Hepatology Teaching Hospital who had been diagnosed as having gastroesophageal reflux disease by the use of endoscopy were included but had no prior history of any other systemic diseases. Exclusion criteria: Any patient who has another kind of systemic disease including diabetes, respiratory infection, cardiovascular disease, metabolic syndrome, patients wearing appliances, patients who are smokers, and patients receiving medication for any other disease. Smith and Knight (1984) tooth wear index criteria were used to examine and record the surfaces of all teeth (22), using a plain mouth mirror and light-emitting diode (LED) headlight for illumination. The collection of unstimulated saliva was accomplished by passive drooling 0f saliva in graduated test tubes for five minutes, this was accomplished as directed by the University of Southern California School 0f Dentistry (23). Previous to the starting 0f saliva samples collection, it should be confirmed by the patients that in the last hour, excluding water, they did not drink or eat anything. After washing the oral cavity with distilled (deionized) water, the patient was instructed to rest in a relaxed position for (5) minutes in previous to the beginning of collection process. During this procedure movement should be minimized, particularly the movement of the mouth. The patient is then told to swallow in order to clear the mouth of saliva while beginning the process with a slight mouth opening to allow saliva to dribble into the graded tube and with a forward inclination 0f the head. the last step, when the five minutes ended, the patients were instructed to gather all of the mouth's leftover saliva and expectorate it inside the tube, and this step should be achieved as fast as possible. The flow rate was then determined by dividing the milliliters (ml) 0f the entire saliva collected by the minute (min) it took to collect the saliva (24). Salivary pH has been measured by using a digital pH meter by immersing it in the tube of the saliva sample, then waiting for about thirty seconds in order to have a stable reading and record the result. The pH meter was calibrated every day by using two pH solutions (pH=4.01, pH=7.01) as recommended by manufacturer instruction, then washing and disinfecting the head of the pH meter by washing it with running distilled water and then alcohol disinfectant was used and finally dried with filter paper. The statistical analysis was completed with the Statistical Package for Social Science (SPSS version -22, Chicago, Illinois, USA). Using descriptive analysis which includes mean, standard error, and a cluster chart bar. Inferential analysis was used as an independent sample T-test parametric test to determine the difference between the two groups. The Pearson correlation parametric test was used to determine if two quantitative variables were linearly related. Results From the whole sample (90%) was recorded tooth wear. Regarding GERD severity, the prevalence of tooth wear was found to be higher among grade B(mucosal breakage longer than 5 mm) GERD severity than grade A(mucosal breakage not longer than 5 mm) GERD severity in different surfaces of both jaws except in lingual, mandibular buccal (Mand.B.) and mandibular cervical (Mand.cer.) surfaces as shown in figure (1). J. Bagh. Coll. Dent. Vol. 35, No. 2. 2023 Abdulrazak et al 4 Table (1) illustrates tooth wear according to GERD severity by disease duration. The results showed that in patients with two years or less of tooth wear the mean value of tooth wear was higher in grade B, while the mean value of tooth wear was higher in grade A in patients with a duration of more than two years without statistically significant difference, except at mandibular buccal tooth wear in patients with a duration of more than two years. Results of salivary flow rate (SFR) and pH among GERD severity in patients with a duration of two years or less and a duration of more than two years are illustrated in Table (2). Although SFR and pH were higher in grade A than in grade B in both durations, there was no statistically significant difference. TTW: total tooth wear, MaxTW: maxillary tooth wear, MAXOI: maxillary occlusal or incisal, MAXB: maxillary buccal, MAXCER: maxillary cervical, MANDTW: mandibullar tooth wear, MANDO: mandibular occlusal, MANDB: mandibullar buccal, MANDCER: mandibular cervical. Figure 1: The percentage of patients who have tooth wear in the total sample by severity of gastroesophageal reflux disease. A: one (or more) mucosal breakage not longer than 5 mm that does not continue between the peak of two esophageal mucosal folds. 0 10 20 30 40 50 60 70 80 90 100 A B % J. Bagh. Coll. Dent. Vol. 35, No. 2. 2023 Abdulrazak et al 5 B: one (or more) mucosal breakage more than 5 mm long that does not continue between the peak of two esophageal mucosal folds. Table 1: Descriptive and statistical test of tooth wear among severity of gastroesophageal reflux disease by disease duration. Duration (years) GERD SEVERITY A B MEAN ±SE MEAN ±SE T test P value^ <=2 TTW 28.875 4.668 39.576 5.579 1.471 0.146 MAXTW 14.344 2.317 21.545 3.003 1.899 0.062 MAXOI 10.094 1.149 11.939 1.058 1.182 0.242 MAXB 1.125 0.575 2.212 0.849 1.060 0.294 PALATAL 2.094 0.647 4.394 1.023 1.900 0.063 MAXCER 1.031 0.556 3.000 0.896 1.867 0.067 MANDTW 14.531 2.504 18.030 2.733 0.944 0.349 MANB 0.844 0.533 1.727 0.803 0.917 0.363 MANDO 10.094 1.285 12.000 0.944 1.195 0.237 LINGUAL 1.500 0.679 2.212 0.831 0.663 0.510 MANDCER 1.781 0.750 2.091 0.836 0.276 0.784 2+ TTW 50.091 9.757 31.692 5.408 1.649 0.109 MAXTW 26.000 4.811 17.615 3.400 1.423 0.164 MAXOI 13.773 1.870 11.231 1.997 0.929 0.360 MAXB 3.182 1.137 1.231 0.794 1.407 0.169 PALATAL 5.773 1.272 3.769 1.490 1.023 0.315 MAXCER 3.273 1.181 1.385 0.805 1.321 0.196 MANDTW 24.091 4.996 14.077 2.704 1.763 0.088 MANB 3.636 1.207 0.154 0.154 2.862 0.009 MANDO 13.500 2.062 11.615 2.086 0.643 0.525 LINGUAL 3.409 1.145 0.923 0.711 1.845 0.074 MANDCER 3.545 1.150 1.385 0.805 1.539 0.133 Total TTW 37.519 4.997 37.348 4.285 0.025 0.980 MAXTW 19.093 2.493 20.435 2.354 0.387 0.699 MAXOI 11.593 1.041 11.739 .935 0.103 0.918 MAXB 1.963 .585 1.935 .648 0.032 0.974 PALATAL 3.593 .684 4.217 .839 0.583 0.561 MAXCER 1.944 .596 2.543 .686 0.663 0.509 MANDTW 18.426 2.573 16.913 2.105 0.445 0.657 MANDB 1.981 .608 1.283 .585 0.821 0.414 MANDO 11.481 1.145 11.891 .885 0.276 0.783 LINGUAL 2.278 .623 1.848 .631 0.482 0.631 MANDCER 2.500 .650 1.891 .639 0.663 0.509 J. Bagh. Coll. Dent. Vol. 35, No. 2. 2023 Abdulrazak et al 6 Table 2: Descriptive and statistical test of salivary Flow rate and PH among GERD severity by duration. Duration (years) GERD severity A B Mean ±SE Mean ±SE T P value <=2 SFR 0.563 0.050 0.497 0.050 0.934 0.354 pH 6.622 0.070 6.588 0.073 0.334 0.740 2+ SFR 0.464 0.054 0.346 0.071 1.318 0.197 pH 6.650 0.093 6.569 0.106 0.554 0.583 Total SFR 0.522 0.037 0.454 0.042 1.221 0.225 pH 6.633 0.056 6.582 0.060 0.620 0.537 SFR: salivary flow rate pH: salivary pH Results in table (3) show that Tooth wear's correlations with pH and SFR are not significant weak correlations in the severity of group B GERD, while significant negative weak correlations with SFR in group A GERD severity, while in pH with group A, A non-significant negative weak correlations are found in palatal, max. and mand. Cerv., and mand. BW. Table 3: correlations of tooth wear with salivary flow rate and pH in GERD severity. Vars. SFR GERD severity PH GERD severity A B A B r p value r p value r p value R p value TTW -0.369* 0.006 -0.210 0.161 -0.379* 0.005 -0.153 0.309 MAXTW -0.363* 0.007 -0.182 0.225 -0.380* 0.005 -0.184 0.220 MAXOI -0.278* 0.042 0.060 0.692 -0.419* 0.002 -0.222 0.138 MAXB -0.287* 0.036 -0.204 0.173 -0.308* 0.024 -0.147 0.330 Palatal -0.410* 0.002 -0.213 0.155 -0.260 0.058 0.040 0.789 MAXCER -0.280* 0.041 -0.254 0.088 -0.259 0.059 -0.240 0.108 MANDTW -0.366* 0.007 -0.224 0.134 -0.368* 0.006 -0.106 0.481 MANDO -0.303* 0.026 -0.033 0.827 -0.414* 0.002 -0.146 0.333 MANDB -0.328* 0.016 -0.186 0.215 -0.183 0.185 0.008 0.957 Lingual -0.292* 0.032 -0.263 0.078 -0.285* 0.037 -0.073 0.631 MANDCER -0.266* 0.052 -0.263 0.077 -0.239 0.082 -0.084 0.579 *=significant atp<0.05, TTW: total tooth wear, MaxTW: maxillary tooth wear, MAXOI: maxillary occlusal or incisal, MAXB: maxillary buccal, MAXCER: maxillary cervical MANDTW: mandibullar tooth wear, MANDO: mandibular occlusal, MANDB: mandibullar buccal MANDCER: mandibular cervical. J. Bagh. Coll. Dent. Vol. 35, No. 2. 2023 Abdulrazak et al 7 Discussion In spite of symptomatic GERD becoming a common condition in our population and chronic duration of the disease have been recognized among GERD patients (25), there are no previous reports in the literature on the oral findings among GERD patients in Iraq. Considering the upper gastrointestinal (GI) endoscopy as the gold standard for GERD confirmation (26) for this reason the included patients in this study were those who had been diagnosed as having GERD by the use of upper GI endoscopy. The patients were diagnosed and classified according to the Los Angeles (LA) classification (9). There is strong evidence linking changes in the oral cavity to alterations in systemic health (27, 28). Due to the fact that the oral cavity is a component of the digestive system, gastrointestinal illnesses may appear as oral disorders (29). In this study a high frequency of tooth wear was found in this study (90%) These results were similar to those found in previous studies (18, 30-33) who reported a significant association between tooth wear and GERD. Unlike the results of Jensdottir and colleagues who reported a low prevalence of dental erosion among GERD patients (34). Results of this study concerning GERD duration found that patients with tooth wear were higher in grade B than in grade A among patients with a duration of two years or less, while tooth wear was higher in grade A than grade B among patients with longer duration (more than two years), this could be explained by that GERD patients did not tend to cross over from one grade to another in a follow-up periods range from (6) months to longer than (22) years (35, 36). In this study, salivary flow rate and salivary pH were higher in grade A than in grade B although without statistically significant differences, but these results agree with the results found by Preetha et al. (37) who found that there was an inverse relationship between salivary flow rate and pH and GERD severity grade. Furthermore, Tooth wear’s correlation with salivary pH and salivary flow rate is a negative correlation in both grade A and B severity which agree with Agbor et al. (38) and this could be due to the reduction of salivary flow rate among GERD patients (33) as long as saliva is considered to be the main defense mecha- nism from acid exposure present in the oral cavity so any change in the amount and quality of saliva will affect its defensive roll by acid clearance and neutralization (39). While lowered pH of the oral cavity due to acid reflux could lead to the dissolution of the inorganic material of the teeth (dissolution of hydroxyapatite crystals in the tooth enamel), and then to dental erosion making the teeth to be predisposed to friction (wear of the tooth) (40). Conclusion From the present study, it could be concluded that a high incidence of tooth wear could be noticed among GEDR patients and this would be related to salivary flow rate and pH reduction among GERD patients. GERD patients need to regularly visit a dentist to get proper preventive programs and a dentists physicians cooperation is very important to prevent or reduce further oral effects of GERD. Conflict of interest: None. References 1. Bartlett D, Evans D, Smith B. Oral regurgitation after reflux provoking meals: a possible cause of dental erosion? J. Oral Rehabil. 1997;24(2):102-8. (Crossref) 2. Ranjitkar S, Kaidonis JA, Smales RJ. Gastroesophageal reflux disease and tooth erosion. Int. J. 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(Crossref) المعدي المريئي االرتجاع بين مرض الفيزيائيةتآكل األسنان فيما يتعلق بخصائص اللعاب العنوان: علي إسماعيل فالح ,ألحان أحمد قاسم ,مروة صديق عبد الرزاق الباحثون: : المستخلص هواء إلى الفم. العديد من الخلفية: مرض االرتجاع المعدي المريئي ، وهو مرض منتشر جدا في الجهاز الهضمي ، والذي يمكن أن يحدث فيه عودة محتوى المعدة بخالف ال رجة الحموضة. أجريت هذه الدراسة على مرضى المظاهر الفموية المرتبطة بهذا المرض بما في ذلك تآكل األسنان وتسوس األسنان والتغيرات في معدل تدفق اللعاب ود المعدي المريئي على االرتجاع االرتجاع المعدي المريئي من أجل تقييم تآكل األسنان فيما يتعلق بمعدل تدفق اللعاب ودرجة الحموضة بين هؤالء المرضى وتأثير مدة مرض عية ، وكانوا يترددون على المستشفى التعليمي ألمراض الجهاز الهضمي والكبد في بغداد والذين تم هذه العالقة. المواد والطرق: شارك مائة مريض في هذه الدراسة المقط وكال الجنسين. تم استخدام معايير مؤشر عاًما 40-20( ، والذين تتراوح أعمارهم بين LAتشخيصهم بالمنظار بمرض االرتجاع المعدي المريئي وفقًا لتصنيف لوس أنجلوس ) النتائج: من العينة .( لتقييم تآكل األسنان. تم جمع عينات اللعاب غير المحفزة لتقدير معدل تدفق اللعاب ودرجة الحموضة1984) Smith and Knightتآكل األسنان الغشاء )كسر Aفي شدة الدرجة مم( منه 5)كسر الغشاء المخاطي بطول أكثر من B٪( كان لديهم تآكل في األسنان. كان تآكل األسنان أعلى في شدة الدرجة 90بأكملها ) بين Bمما كانت عليه في الدرجة Aمم( بين المرضى الذين يعانون من ارتجاع المريء لمدة عامين أو أقل ، في حين أنه كانت أعلى في الدرجة 5ال يزيد عن المخاطي الذين تزيد مدتهم عن عامين ولكن كل هذه النتائج كانت غير معنوية إحصائياً. ودرجة الحموضة انخفاًضا طفيفًا مع زيادة شدة مرض المرضى أظهر معدل تدفق اللعاب لبيًا ضعيفًا بشكل ملحوظ المريئي لكال المجموعتين فيما يتعلق بمدة المرض. كان االرتباط بين تآكل األسنان الكلي ومعدل تدفق اللعاب ودرجة الحموضة ارتباطًا س االرتجاع . االستنتاجات: خلصت نتائج الدراسة الحالية إلى أن مرضى االرتجاع المعدي المريئي سجلوا ارتفاعًا Bسلبي الضعيف غير المعنوي في الدرجة بينما االرتباط ال Aفي الدرجة تآكل األسنان وكان هناك ارتباط سلبي لتآكل األسنان مع معدل تدفق اللعاب ودرجة الحموضة بين مرضى االرتجاع المعدي المريئي. https://doi.org/10.1016/j.tripleo.2010.02.025 https://doi.org/10.1016/S1590-8658(03)00215-9 https://doi.org/10.1155/2014/818167 https://doi.org/10.1097/MEG.0000000000000622 https://doi.org/10.1186/s12876-017-0650-5 https://doi.org/10.1007/s00784-003-0252-1 http://eprints.southarchive.com/id/eprint/223 https://doi.org/10.1111/j.1875-595X.2011.00063.x https://doi.org/10.1111/j.1601-0825.2007.01380.x