Role of a Dental Hygienist in Controlling Oral Manifestations

What is the role of a dental hygienist in controlling oral manifestations? Gastroesophageal reflux disease involves reflux of acidic gastric contents into the esophagus, most commonly due to the defect of the lower esophageal sphincter. This produces the familiar sensation of heartburn. It is one of the most common diseases worldwide and adversely affects the living standard. Almost half of all adults will report reflux symptoms at sometime1.

The reflux of the gastric contents, including the food and enzymes such as pepsin, into the laryngopharynx, is termed Laryngopharyngeal reflux disease and is accompanied by symptoms of dysphonia, chronic cough, and mild dysphagia2.

The lower esophageal sphincter is located at, the lower end of the esophagus. It relaxes to allow the movement of food and liquid into the stomach, after which it closes. However, in patients with GERB and LPR, it fails to close and remains relaxed. This accounts for the stomach acid to regurgitate back into the esophagus3. For LPR, the upper esophageal sphincter also remains unable to close, leading to reflux into the pharynx and oral region4.

Risk Factors:

Following are some of the common risk factors for GERD:

  1. Nicotine consumption
  2. Caffeine consumption
  3. Alcohol consumption
  4. Obesity5

Some other uncontrollable risk factors include:

  1. Pregnancy
  2. Hiatal hernia
  3. Medications5

 

Signs and Symptoms:

Some of the common symptoms leading to discomfort and early diagnosis of Gerd include:

  1. Heartburn
  2. Inflammation
  3. Irritation of the esophagus

Some uncommon symptoms that may be associated with Gerd include:

  1. Chronic cough
  2. Noncardiac chest pain
  3. Asthma6

Symptoms of LPR include:

  1. Hoarseness of voice
  2. Frequent need to clear throat
  3. Excessive mucus formation
  4. Trouble swallowing food
  5. Bitter taste in the mouth
  6. Breathing difficulty7

These symptoms may worsen at night or while lying supine. One thing not commonly known is that both GERD and LPR can cause severe oral manifestations that can also be pre-cancerous.

 

Oral Manifestations:

The oral manifestations of GERD and LPR include:

  1. Dental erosion:

Dental erosion is one of the GERD complications that may be ruled out with routine dental hygiene inspection. It is the wearing off of the enamel of the teeth due to chemical processes. The eroded parts may appear yellow, have rounded cusps, cupping of occlusal surfaces, and the restorations are above the level of other tooth structures8. The maxillary anterior lingual surface is the most frequently affected victim of GERD mediated erosion and can also extend to the anterior mandibular teeth9.

Dental erosion is prevalent in 24% of the adults with GERD10 and almost 98% of the children affected by GERD11.

 

  1. Xerostomia:

Xerostomia is the feeling of dryness of the mouth caused by inadequate production of saliva by the salivary glands, thus inability to keep the mouth wet12. GERD patients also face a reduction in the salivary flow inside the oral cavity, thus leading to a lower buffering capacity of this cavity than people without gastrointestinal complications. The saliva has a crucial role in neutralizing pH and keeping the oral cavity cleansed from oral disease-causing organisms, thus posing risks for GERD patients. These patients are almost twice as likely to experience xerostomia when considering age and saliva composition13.

 

  1. Oral malodor:

Intestinal acids and their odors are confined to the GI tract in normal individuals.  However, in those individuals with GERD and/or LPR, these acids, odors, and occasionally even bacteria can gain entry into the oral cavity and cause malodor. This malodor may be suspected to be a product of poor oral hygiene, but a physician must also consider systemic diseases like GERD for early diagnosis of underlying pathology14.

 

The Role of a Dental Hygienist in Controlling Oral Manifestations

There may be grave health implications of GERD and LPR. Therefore, dental hygienists should screen for GERD symptoms alongside oral cancer, which should start with the thorough medical and dental history of every presenting patient.

After completion of a thorough history, the oral cavity should be assessed for signs of GERD, regardless patient’s health history indicates GERD or not. When any signs such as xerostomia, malodor, or dental erosion are noted, the dentist should keep detailed documentation in the patient chart and begin taking a history regarding gastrointestinal (GI)l diseases. If unaware of any prevalent GI diseases, the dentist should inquire about the etiology of these nontraditional symptoms and ask him/her to complete the reflux symptom index (RSI), a fast and reliable tool to help identify patients with GERD or LPR7.

Once GERD/LPR is identified, discuss with the supervising dentist, educate the patient on the findings and possible remedies under the dental scope of practice. Nonpharmaceutical treatments for GERD and LPR, including lifestyle and dietary modifications like losing weight and reducing or eliminating tobacco, alcohol, carbonated drinks, late-night snacking, and chocolate, should be discussed. In addition to diet changes, dental interventions in enamel erosion to prevent further destruction and strengthen the current tooth structure should be discussed. Patients with GERD should avoid mints and flavored gums, otherwise indicated for xerostomia, as these can increase GERD symptoms severely15.

 

Conclusion:

GERD and LPR involving acid reflux can present with untraditional symptoms involving the oral cavity like dental damage and malodor. Therefore, the dentist needs to be diagnosed and counseled to prevent further oral damage and progression of pre-cancerous states. Therefore, a detailed history and counseling by the dentist is a need in every patient with oral hygiene problems.

Interested in learning more about the role of a dental hygienist in controlling oral manifestations? Check out my online CE Courses available today! https://www.tomviola.com/ce/ 

References:

  1. Locke GR, 3rd, Talley NJ, Fett SL, Zinsmeister AR, Melton LJ., 3rd Prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in Olmsted County, Minnesota. Gastroenterology. 1997;112:1448–1456.
  2. Franco RA Jr. Laryngopharyngeal reflux. Allergy Asthma Proc. 2006;27(1):21-25.
  3. Mayo Clinic. Gastroesophageal Reflux Disease. Available at: mayoclinic.org/diseases-conditions/gerd/symptoms-causes/svc-20361940. Accessed November 18, 2021.
  4. Martinucci I, de Bortoli N, Savarino E, et al. Optimal treatment of laryngopharyngeal reflux disease. Ther Adv Chronic Dis. 2013;4:287–301.
  5. Ranjitkar S, Kaidonis JA, Smales RJ. Gastroesophageal reflux disease and tooth erosion. Int J Dent. 2012;2012:479850.
  6. Wood JM, Hussey DJ, Woods CM, Watson DI, Carney AS. Biomarkers and laryngopharyngeal reflux. J Laryngol Otol. 2011;125:1218-1224.
  7. Campagnolo AM, Priston J, Thoen RH, Medeiros T, Assunção AR. Laryngopharyngeal reflux: diagnosis, treatment, and latest research. Int Arch Otorhinolaryngol. 2014;18(2):184-191. doi:10.1055/s-0033-1352504
  8. Dunbar A, Sengun A. Dental approach to erosive tooth wear in gastroesophageal reflux disease. Afr Health Sci. 2014;14:481–486.
  9. Valena V, Young WG, Dental erosion patterns from intrinsic acid regurgitation and vomiting. Aust Dent J. 2002;2:106–115.
  10. Yoshikawa H, Furuta K, Ueno M, et al. Oral symptoms including dental erosion in gastroesophageal reflux disease are associated with decreased salivary flow volume and swallowing function. J Gastroenterol. 2012;47:412–420.
  11. Canadian Society of Intestinal Research. GERD and Dental Erosion. Available at: badgut.org/information-centre/a-z-digestive-topics/gerd-dental-erosion/. Accessed November 20, 2020.
  12. Talha B, Swarnkar SA. Xerostomia. In: StatPearls. Treasure Island (FL): StatPearls Publishing; June 4, 2021.
  13. Campisi G, Lo Russo L, Di Liberto C, et al. Saliva variations in gastro-oesophageal reflux disease. J Dent. 2008;36:268–271.
  14. Campisi G, Musciotto A, Di Fede O, Di Marco V, Craxì A. Halitosis: Could it be more than mere bad breath? Intern Emerg Med. 2011;6:315–319.
  15. Koufman JA. Low-acid diet of recalcitrant laryngopharyngeal reflux: therapeutic benefits and their implications. Ann Otol Rhinol Laryngol. 2011;120:281–287.

 

 

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