CLINICAL RESEARCH

Prevalence of dental erosion among people with

gastroesophageal reflux disease in China
Wenhao Li, MS,a Jingming Liu, MS,b Su Chen, MD,c Yao Wang, MS,d and Zhenting Zhang, MDe

Gastroesophageal reflux dis- ABSTRACT

ease (GERD), one of the most Statement of problem. Gastroesophageal reflux disease (GERD) is typically diagnosed based on
frequently seen diseases in the symptoms of regurgitation and heartburn, although it may also manifest as asthma-like symptoms,
gastroenterology clinic, in- laryngitis, or dental erosion.
volves the reflux of gastric
Purpose. The purpose of this prospective, cross-sectional study was to assess the prevalence of
contents into the esophagus, dental erosion in people with GERD and to evaluate the association between GERD and dental
oral cavity, or lung.1 Atypical erosion.
presentations of GERD include
Material and methods. The presence, severity, and pattern of dental erosion was assessed in 51
asthma-like symptoms, chronic
participants with GERD and 50 participants without GERD using the Smith and Knight tooth wear
cough, and noncardiac chest index. Medical, dietary, and dental histories were collected by questionnaire. Factors potentially
pain.2 More than 40% of related to dental erosion, including GERD, were evaluated by logistic regression.
American adults experience
Results. Dental erosion was observed in 31 (60.8%) participants with GERD and 14 (28%) partici-
reflux symptoms on a monthly pants without GERD. Bivariate analysis revealed that participants with GERD were more likely to
3
basis. In Asia, the prevalence experience dental erosion (crude odds ratio [cOR]: 2.74; 95% CI: 1.19, 6.32) than participants without
of GERD ranges from 2.5% to GERD. Multivariate analysis also revealed that participants with GERD had a higher risk of dental
6.7% and has increased in erosion (adjusted odds ratio [aOR]: 3.97; 95% CI: 1.45, 10.89). Consumption of grains and legumes,
recent years,4 but it varies the most frequently consumed foods in China, did not correlate with dental erosion. However,
according to the method of carbonated beverage consumption was significantly associated with GERD and dental erosion (aOR:
3.34; 95% CI: 1.01, 11.04; P=.04).
diagnosis.5-7
Because gastric juices are Conclusions. GERD was positively correlated with dental erosion. Carbonated beverage con-
regurgitated up to the larynx sumption can increase the risk of both GERD and dental erosion. (J Prosthet Dent 2016;-:---)
and oral cavity, a range of oral
symptoms are common findings in people with GERD, processes, including chemical and electrolytic pro-
including pruritus and irritation of the oral mucosa, tooth cesses.11 During active erosion, the tooth may become
sensitivity, aphthae, sour taste, and dental erosion. Pre- very sensitive to temperature changes.
vious studies have indicated that people with regular oral Regurgitated intrinsic acids have a pH of less than 2.0,
exposure to gastric juices, such as those with GERD, are below the critical pH level of 5.5, and have the potential
at high risk of developing dental erosion and that the to dissolve the hydroxyapatite crystals in enamel and
severity of GERD is associated with the severity of dental cause other soft tissue symptoms.12 In people with
8-10
erosion. Dental erosion is described as the loss of the GERD, chronic exposure to extrinsic or intrinsic acid can
tooth surface as a result of non-bacteria-associated increase the dissolution of dental hard tissues, resulting

a
PhD student, Department of Prosthodontics, Capital Medical University School of Stomatology, Beijing, China; and PhD student, Department of Stomatology,
Beijing Tong Ren Hospital, Capital Medical University, Beijing, China.
b
Professor, Department of Stomatology, Beijing Tong Ren Hospital, Capital Medical University, Beijing, China.
c
Professor, Department of Prosthodontics, Capital Medical University School of Stomatology, Beijing, China.
d
Associate professor, Department of Gastroenterology, Beijing Tong Ren Hospital, Capital Medical University, Beijing, China.
e
Professor, Department of Prosthodontics, Capital Medical University School of Stomatology, Beijing, China.

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Clinical Implications
The diagnosis of gastroesophageal reflux disease
(GERD) often depends on the presence of heartburn
and regurgitation. Multivariate analysis revealed
that Chinese people with GERD had a higher risk of
dental erosion, indicating that dental erosion may
be a symptom of GERD in the Chinese population.
in dental erosion13 that especially affects the dental
enamel on the palatal tooth surfaces.14
A previous study has assessed the relationship be-
tween dental erosion and respiratory symptoms in peo-
ple with GERD. The prevalence of dental erosion was
highest in participants with GERD who experienced
frequent respiratory symptoms.15 Nwokediuko8 sug-
gested that acid reflux was more severe in people with
GERD and frequent respiratory diseases and so more
frequently affected the oral cavity and pharynx, causing
more severe dental erosion. Therefore, he emphasized
that the presence of GERD could influence the preva-
lence of dental erosion.8
Although evidence of an association of GERD with
dental erosion is accumulating, less than 50% of physi-
cians agree that such an association exists in adults.
Contrary to some physicians’ opinions, a recent sys-
tematic review reported that tooth erosion was present in
a median of 24% of people with GERD.5 However, other
studies have reported no significant association between
these conditions. A large case-control study of Italian
adults did not find that GERD was associated with either
dental erosion or tooth sensitivity.16 Furthermore, in a
study of Californian children, dental erosion was not
found to be associated with GERD.17 Another study has
reported a low prevalence of dental erosion in people
with GERD.18 The implications of these studies may
inform the diagnosis and management of GERD, but
further investigations will be required to confirm the
relevance of dental erosion in GERD.
Several factors have been reported to be associated
with GERD and/or dental erosion. For example, the
consumption of carbonated beverages has been impli-
cated in the aggravation of GERD19-23 and dental
erosion,24-26 while the intake of milk products has been
suggested to be associated with dental erosion.27
Smoking is also thought to contribute to GERD.28
The association between GERD and dental erosion
has not been studied in the Chinese population. Given
the difference in the prevalence of GERD between Asian
and non-Asian populations, we hypothesized that
studying the association between GERD and dental
erosion might identify a useful diagnostic marker in this
population. This study assessed the prevalence of dental
THE JOURNAL OF PROSTHETIC DENTISTRY
- Issue -
erosion in people with and without GERD in China, and
evaluated the association between GERD and dental
erosion. In addition, we investigated the possible asso-
ciation of various dietary factors with dental erosion.
MATERIAL AND METHODS
This was a cross-sectional study of people attending the
Department of Stomatology, Beijing Tong Ren Hospital
of Capital Medical University between May 2014 and July
2014. All participants were residents of Beijing and aged
18 to 70 years. After they had provided written informed
consent, the enrolled participants were asked to complete
a structured questionnaire that collected their de-
mographic characteristics and dietary, dental, and med-
ical histories. The dental history included details of any
past dental treatment, tooth restoration, or extraction.
The medical history included information regarding the
symptoms, diagnosis, and treatment of GERD and any
medications taken.
For the analysis, the participants were divided into 2
groups: those with GERD and those without GERD. The
diagnosis of GERD was based on the following two
criteria: a history of heartburn or reflux occurring at least
3 times per week and/or a mucosal break on esophageal
endoscopy. Upper endoscopy may not be required in the
presence of typical GERD symptoms but is recom-
mended in the presence of alarming symptoms and for
screening people at high risk of complications.1 However,
because endoscopy has excellent specificity for the
diagnosis of GERD, particularly when erosive esophagitis
is seen and the Los Angeles classification is used,29 this
was used as an additional diagnostic criterion.
Participants with concomitant systemic diseases,
active periodontitis, anorexia or bulimia nervosa, or who
were pregnant or receiving medications that may cause
heartburn were excluded. The study also excluded par-
ticipants who had bruxism or any other behavior that
might be associated with tooth wear; a history of un-
usually high acidic juice consumption or environmental
exposure to acid; or orthodontic appliances, bleaching,
dental fluorosis, or tetracycline pigmentation of the teeth.
The study was approved by the ethics committee at our
hospital (Clinical Trials 2014BJSZR-10).
The palatal surfaces of the maxillary teeth are the
most common site affected by GERD.30 The distribution
and severity of any dental erosion was evaluated by a
senior dentist (W.L.) using the Smith and Knight tooth
wear index (Table 1).31 The palatal surfaces of all maxil-
lary teeth were scored between 0 and 4, where 0 repre-
sents no erosion and 4 represents complete enamel loss
exposing the pulp or secondary dentin. All teeth were
thoroughly cleaned and dried using cotton wool buds.
Third molars, teeth out of place or with tetracycline
pigmentation, fluorosis, multiple or large caries, large
Li et al
- 2016 3

Table 1. Criteria for grading erosive wear score: Smith and Knight tooth Table 2. Demographic characteristics and dietary history by GERD
wear index GERD Without GERD
Score Surface Criterion Characteristic (N=51) (N=50) P

0 B/L/O/I No loss of enamel surface characteristics Sex, n (%)

C No loss of contour Male 15 (29) 20 (40)
1 B/L/O/I Loss of enamel surface characteristics Female 36 (71) 30 (60) .26
C Minimal loss of contour
Age (y), median (SD)
2 B/L/O Loss of enamel exposing dentine for less than one third
Median 53 (15) 41 (12) <.01
of surface
I Loss of enamel just exposing dentine Male 53 (15) 35 (11) <.02
C Defect less than 1 mm deep Female 53 (15) 49 (12) .15
3 B/L/O Loss of enamel exposing dentine for more than one third Education, n (%)
of surface
I Loss of enamel and substantial loss of dentine High school 14 (27) 10 (20)
C Defect less than 1 to 2 mm deep College 29 (57) 26 (52)
4 B/L/O Complete enamel loss, pulp exposure, secondary dentine Graduate school 8 (16) 14 (28) .29
exposure
Grains and legumes per day, n (%)
I Pulp exposure or exposure of secondary dentine
C Defect more than 2 mm deep, pulp exposure, secondary <300 g 48 (94) 46 (92)
dentine exposure 300 g 3 (6) 4 (8) .68
B, buccal or labial; L, lingual or palatal; O, occlusal; I, incisal; C, cervical. Milk per day, n (%)
<300 mL 34 (67) 25 (50)
300 mL 17 (33) 25 (50) .09
restorations, fractures, or dental prostheses were Yogurt, n (%)
excluded from analysis. All examinations were carried out Yes 26 (51) 26 (52)
in a blinded fashion using standardized criteria by No 25 (49) 24 (48) .92
experienced dentist (W.L.) who had undergone suitable Carbonated beverages, n (%)
training and calibration exercises in the use of the Smith Yes 12 (24) 21 (42)
and Knight index. With regard to reliability, intra- No 39 (76) 29 (58) .04
examiner reproducibility was assessed by remeasuring Smoking, n (%)
the Smith and Knight index in 10 randomly selected Yes 8 (16) 6 (12)
participants (every 10th participant enrolled; 10% of the No 43 (84) 44 (88) .59
total), with the repeat measurement made more than 15 GERD, gastroesophageal reflux disease; SD, standard deviation.
days after the initial measurement. The Kappa value for
intraobserver reproducibility was calculated to be 0.90,
RESULTS
indicating excellent agreement between examinations
and thus high reliability. Of the 101 participants enrolled in the study, 51 partici-
The GERD prevalence, stratified by the demographic pants had GERD and 50 were without GERD. The age
characteristics and dietary history, was calculated. The distribution of the study population was uneven, and the
Fisher exact test, Chi-square test, and Wilcoxon-Mann- participants with GERD were older than those without
Whitney test were applied to compare the prevalence GERD (P<.01). The study participants chiefly consisted of
of dental erosion between participants with GERD and women (36 with GERD and 30 without GERD). The
those without GERD, stratified by the demographic median ages of the male and female participants with
characteristics and dietary history (a=.05). GERD were the same, whereas the median age of male
For calculations of the prevalence of dental erosion in participants without GERD (35, 11 years) was less than
each group, the presence of dental erosion in a partici- that of female participants without GERD (49, 12 years).
pant was defined as erosion of at least 1 tooth. In addi- Participants with and without GERD were comparable in
tion, the frequency of each level of erosion, based on the terms of education, smoking status, milk consumption,
Smith and Knight tooth wear index score, was deter- yogurt consumption, and grain and legume consumption
mined for the palatal surfaces of the maxillary teeth. (Table 2). Only carbonated beverage consumption was
Logistic regression analysis was used to estimate the found to be significantly associated with GERD (P=.04).
crude and adjusted odds ratios (cOR and aOR, respec- The erosion scores for the palatal surfaces of the
tively) and 95% confidence intervals (CIs) for the asso- maxillary teeth were recorded. Overall, 0.6% of all teeth
ciation between GERD and dental erosion. The were graded as having level 4 erosion. The highest wear
associations between various covariates and dental rates were seen on the palatal surfaces of the incisor
erosion were also evaluated using bivariate and multi- (Fig. 1). Participants with GERD had a higher prevalence
variate analysis. The covariates for the multivariate of dental erosion than those without GERD (60.8%
analysis were selected based on biologic importance. The versus 28.0%; cOR: 2.74; 95% CI: 1.19, 6.32). Similar
results were analyzed using software (SAS v9.2; SAS results were obtained in the multivariate analysis (aOR:
Institute) (a=.05). 3.97; 95% CI: 1.45, 10.89). In addition, the dietary habits

Li et al THE JOURNAL OF PROSTHETIC DENTISTRY

4 Volume
Maxillary Teeth
Left second molar
Left first molar
Left second premolar
Left first premolar
Left canine
Left lateral
Left central
Right central
Right lateral
Right canine
Right first premolar
Right second premolar
Right first molar
Right second molar
15 10 5 0
Without GERD
Figure 1. Scores of palatal surface erosion of maxillary teeth. GERD, gastroesophageal reflux disease.
were studied to evaluate whether there might be an as-
sociation with dental erosion (Table 3). Only carbonated
beverage consumption was found to be significantly
associated with dental erosion in the multivariate anal-
ysis (aOR: 3.34; 95%CI: 1.01, 11.04).
DISCUSSION
Numerous studies that have diagnosed GERD either by
esophageal pH or endoscopy have shown significant
associations between GERD and the presence of dental
erosion. However, the association between these 2 con-
ditions has not been previously reported in a Chinese
population. The present study determined the prevalence
of dental erosion in Chinese people with GERD and
assessed the relationship between GERD and dental
erosion. We found that 60.8% of participants with GERD
had dental erosion and that GERD was significantly
associated with dental erosion. Carbonated beverage
consumption was also associated with GERD and dental
erosion. However, no association was found between
dental erosion and sex, smoking, milk consumption, or
grain and legume consumption.
Dental erosion accompanying GERD has been
extensively reported and is believed to be the most
common oral symptom of GERD. A systematic review
has indicated that GERD and dental erosion frequently
coexist, with a median prevalence of 24% (range: 5% to
47.5%).5 The prevalence of dental erosion reported by
previous studies has varied with the criteria used for the
THE JOURNAL OF PROSTHETIC DENTISTRY
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Grade 1
Grade 2
Grade 3
Grade 4
5 10 15 20 25
With GERD
diagnosis of GERD; the lowest incidence was found in
studies defining GERD on the basis of symptoms alone,
whereas the greatest incidence was found in an investi-
gation using diagnostic endoscopy.5 Munoz et al6 eval-
uated the dietary factors and other symptoms associated
with dental erosion, salivary flow rate, and/or GERD in
46 people with cerebral palsy. The prevalence of dental
erosion was assessed by 24-hour pH monitoring, and
was found to be 47.5% in people with GERD. Twenty-
four-hour pH monitoring is the gold standard tech-
nique for the diagnosis of GERD. This diagnosis usually
does not involve the identification of symptoms but de-
fines the development of erosion over time.7
The factors influencing the duration of contact of the
gastric contents with the teeth are important for causing
dental erosion. In our study, the diagnosis of GERD was
based on the participants’ history of heartburn or reflux
and/or endoscopy. Therefore, the criteria used for the
diagnosis of GERD in this study should be comparable
with those of previous studies.
We found a significant association between GERD
and dental erosion (cOR: 2.74; 95% CI: 1.19, 6.32). A
similar result was obtained in the multivariate analysis,
although a wider CI was found (aOR: 3.97; 95% CI: 1.45,
10.89). This finding is comparable with previous studies.
Despite a pathophysiologic basis for the development
of dental erosion in people with GERD, several in-
vestigators have observed that the association is not al-
ways significant. Jensdottir et al18 found a low prevalence
of dental erosion in people with GERD, but their
Li et al
- 2016 5

Table 3. Multivariate analysis of possible risk factors associated with in some of the participants; indeed, it is possible that
dental erosion some of the participants with GERD may have reduced
Crude Odds Ratio Adjusted Odds Ratio their consumption of carbonated beverages after the
Factor (95% CI) (95% CI)
GERD
diagnosis of GERD or the onset of its symptoms (because
Yes 2.74 (1.19-6.32) 3.97 (1.45-10.89)
carbonated beverages may exacerbate GERD; see later).
No 1 1 If this were the case, the recorded levels of carbonated
Age (y) beverage consumption in participants with GERD may
45 0.85 (0.38-1.91) 1.10 (0.36-3.33) have underestimated past levels of consumption.
<45 1 1 Several previous studies have found a significant as-
Sex sociation between carbonated beverage consumption,
Male 1.4 (0.61-3.25) 1.71 (0.55-5.33) GERD, and dental erosion. One study suggested that
Female 1 1 carbonated beverages may exacerbate GERD, dyspepsia,
Grains and legumes per day, g and bloating in European and American people.19
300 0.25 (0.03-2.22) 0.32 (0.03-3.31) Carbonated beverages have also been associated with
<300 1 1
symptom aggravation in people with GERD in Korea.20 A
Milk per day (ml)
possible mechanism is that carbonated beverages may lead
300 0.28 (0.12-0.69) 0.42 (0.13-1.34)
to a transient lowering of the esophageal sphincter pres-
<300 1 1
sure (TLESR) and a reduction in the esophageal pH to less
Yogurt
Yes 0.55 (0.24-1.23) 0.74 (0.25-2.20)
than 4, causing GERD-related symptoms.21-23 Carbonated
No 1 1
beverage consumption can also directly influence dental
Carbonated beverages erosion.24 The erosive potential of carbonated beverages is
Yes 2.38 (1.01-5.59) 3.34 (1.01-11.04) predominantly attributed to the pH and buffering capacity
No 1 1 of the beverage. The pH and buffering capacities of
Smoking beverages vary, generally decreasing from fruit juices to
Yes 0.91 (0.28-2.95) 0.32 (0.07-1.44) fruit-based carbonated beverages to non-fruit-based
No 1 1 carbonated beverages.25 Carbonated beverages are
GERD, gastroesophageal reflux disease. derived from the conversion of dissolved carbon dioxide
(CO2) to bicarbonate (HCO3-) and hydrogen (H+) ions by
the interaction of these with water (H2O) and can also
participants without GERD were younger (mean age, contain additives such as citric acid and phosphoric acid.
21 ±2 years) than those with GERD (mean age, 35 ±10 Even when these beverages become “flat,” the pH remains
years) and consumed more carbonated beverages. Wild low. Wang et al26 demonstrated that children who
et al17 found that dental erosion was not associated with consumed carbonated beverages one or more times per
GERD in children, but the erosion of some permanent week tended to have more dental erosion. Carbonated
teeth in older children by extrinsic acid could have beverage consumption can exaggerate GERD and react
influenced the results. directly with the surface of the enamel, causing dental
In this study, carbonated beverage consumption was erosion by both intrinsic and extrinsic acids.
associated with dental erosion (aOR: 3.34; 95%CI: 1.01, No statistically significant association was found be-
11.04). Our initial observation that the proportion of tween dental erosion and grain or legume consumption in
participants consuming carbonated beverages was our study. Grains and legumes, which comprise insoluble
significantly higher in those without GERD than in those and soluble fibers, are the most important component of
with GERD (Table 2) was perhaps unexpected, as there is the diet in China. The recommended dietary grain and
evidence from previous studies that the consumption of legume intake for adults in China is 300 g per day, but
carbonated beverages may be a risk factor for GERD.19 A whether intake levels are associated with GERD has not
possible reason the data in Table 2 appear to be incon- been previously studied. Limited data suggest that GERD
sistent with previous reports is that, in our study, the is less prevalent in people who consume more fiber.32
median age of the participants with GERD was 53 years, However, in the study by Mulholland et al,33 the risk of
whereas that of the participants without GERD was 41 reflux esophagitis significantly increased with starch
years. Since the consumption of carbonated beverages is intake. The physiologic processes causing GERD in a
likely to be higher in younger individuals, it is possible Chinese population may differ from those implicated in
that the younger age of the participants without GERD the development of GERD in Western populations.
may have contributed to our results. It should also be TLESR is thought to be the main mechanism responsible
noted that the measurement of carbonated beverage for GERD in the Western population.34 However, a pre-
consumption was cross-sectional in nature, and thus may vious study of Chinese people with GERD found that
not have reflected the long-term history of consumption primary peristalsis was impaired, suggesting that

Li et al THE JOURNAL OF PROSTHETIC DENTISTRY

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esophageal motor dysfunction may contribute to the
development of GERD in the Chinese population.4
Additionally, in people with GERD, peristaltic dysfunc-
tion is reported to prolong esophageal acid clearance.35
Soluble fiber may slow the transit of food through the
small intestine and delay gastric emptying. Soluble fiber
may also increase intragastric pressure. A higher con-
sumption of grains and legumes could therefore cause the
storing of food in the proximal stomach and a delay in
stomach emptying. Esophageal acid exposure has been
reported to be positively correlated with slow proximal,
but not distal or total, gastric emptying.36 In contrast,
Bouin et al37 suggested that dietary fiber intake decreased
the incidence of gastroesophageal reflux, increased the
duration of reflux, and did not significantly influence
gastric emptying and acid secretion. In this study, 3 par-
ticipants with GERD consumed more than 300 g per day
of grains and legumes per day; however, we did not
establish a significant relationship between GERD and
the consumption of grains and legumes. Some studies
have reported that the intake of milk products, such as
yogurt, is associated with dental erosion,27 and that
smoking is associated with GERD.28 However, in this
study, GERD and dental erosion were not associated with
smoking or milk consumption.
This study has several limitations. The most important
limitation is the study population size. Since we included
approximately 50 participants in each group, we cannot
generalize our results. Also this study only analyzed the
number of nonrestored lesions, and, as a consequence,
the data do not represent the number of lesions that had
been restored or that had existed in removed teeth. Some
participants with GERD who did not present with
symptoms or a mucosal break on endoscopic examina-
tion may have been misclassified as participants without
GERD. In addition, because this was a cross-sectional
study rather than a case-control study, the ages of the
cases and controls were not matched; because dental
erosion varies with age, the younger age of the partici-
pants without GERD may have contributed to the dif-
ference between groups in loss of tooth structure.
However, after adjusting for age as a possible con-
founding factor in our multivariate analysis, GERD
remained an independent factor associated with erosion.
Finally, recall bias may have influenced the dietary his-
tory reported by participants in the questionnaires.
CONCLUSIONS
Based on the findings from this study, the following
conclusions were made:
1. GERD is significantly associated with dental
erosion.
2. Carbonated beverage consumption was also asso-
ciated with GERD and dental erosion.
THE JOURNAL OF PROSTHETIC DENTISTRY
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In addition, future longitudinal investigations should
explore the progression of dental erosion in the context of
dietary factors and GERD. Physicians should be involved
in the preventive assessment and management of GERD
and dental erosion. People should be aware of the effect
of carbonated beverages on GERD and dental erosion
and make lifestyle changes to decrease the incidence of
these conditions.
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