Alimentary Pharmacology & Therapeutics
Systematic review: gastro-oesophageal reflux disease and dental
lesions
F. PACE*, S. PALLOTTA*, M. TONINI , N. VAKILà & G. BIANCHI PORRO*
*Division of Gastroenterology,
Department of Clinical Sciences
‘‘L. Sacco’’, University of Milan,
Milan;  Department of Physiological
and Pharmacological Sciences,
University of Pavia, Pavia, Italy;
àUniversity of Wisconsin School of
Medicine and Public Health, Madison,
WI and Marquette University College
of Health Sciences, Milwaukee, WI,
USA
Correspondence to:
Dr F. Pace, Division of
Gastroenterology, ‘‘L. Sacco’’
University Hospital, Via G.B. Grassi,
74, 20157 Milan, Italy.
E-mail: fabio.pace@unimi.it
Publication data
Submitted 13 February 2008
First decision 11 March 2008
Resubmitted 20 March 2008
Accepted 20 March 2008
Epub OnlineAccepted 27 March 2008
ª 2008 The Authors
Journal compilation ª 2008 Blackwell Publishing Ltd
doi:10.1111/j.1365-2036.2008.03694.x
SUMMARY
Background
Dental erosion (DE), which is the irreversible loss of tooth substance
that does not involve bacteria ranging from a minimal loss of surface
enamel to the partial or complete exposure of dentine by a chemical
process, is acknowledged as an established extra-oesophageal manifes-
tation of gastro-oesophageal reflux disease (GERD). However, the real
impact of GERD in the genesis of this lesion remains unclear.
Aim
To review the existing literature to assess the relationship between DE
and GERD.
Methods
Studies that assessed the prevalence of DE in individuals with GERD or
vice versa were identified in Medline and the Cochrane Controlled Trials
Register via a systematic research strategy.
Results
Seventeen studies met the selection criteria. Studies, however, differed
greatly as far as design, population methods of diagnosing GERD, dura-
tion of follow-up and, consequently, findings. The median prevalence of
DE in GERD patients was 24%, with a large range (5–47.5%), and the med-
ian prevalence of GERD in DE adults patients was 32.5% (range: 21–83%)
and in paediatric population 17% (range: 14–87%). Children with GERD
are found by a majority of studies at increased risk of developing DEs in
comparison with healthy subjects, as are intellectually disabled people.
Conclusions
This systematic review shows that there is a strong association between
GERD and DE. The severity of DEs seems to be correlated with the pres-
ence of GERD symptoms, and also, at least in adults, with the severity
of proximal oesophageal or oral exposure to an acidic pH. The inspec-
tion of the oral cavity in search for DEs should become a routine
manoeuvre in patients with GERD.
Aliment Pharmacol Ther 27, 1179–1186
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1180 F . P A C E et al.
INTRODUCTION
Dental erosion (DE) is presently recognized as an
important cause of tooth damage both in children and
in adults, occurring in a percentage varying from 2%
of the general population described in the US1 to 5%
reported in Finland.2 It can be defined as the loss of
tooth substance by a chemical process that does not
involve bacteria, in contrast to carious tooth dam-
age.1, 3 In DEs, the extent of damage may range from
a barely noticeable loss of surface lustre evident on a
clean, dry enamel to the partial or complete exposure
of dentine with its characteristic yellow colour through
the thinned overlying enamel.1, 3
Dental erosion is caused by the presence of intrinsic
or extrinsic acid of non-bacterial origin in the mouth,
or by a combination of them.4 Intrinsic sources of acid
include vomiting, regurgitation, gastro-oesophageal
reflux or rumination. Extrinsic sources of acid are
most commonly dietary acids. Medications, in particu-
lar, some asthma drugs, chewable vitamin C tablets or
iron tonics, patient’s lifestyle choices such as unusual
eating and drinking habits, or socio-economic aspects
and environment, can also increase the risk of DE,
particularly in children.5, 6
The first modern description of DEs associated with
gastro-oesophageal reflux disease (GERD) is due to
Howden,7 in a case report published more than
35 years ago. In recent years, GERD has been
described as an important aggravating factor of DEs
and DE is now considered a comorbid syndrome with
an established epidemiological association with GERD.
As an example, the recently published Montreal Crite-
ria, dealing with a global classification of GERD, state:
‘The prevalence of DEs, especially on the lingual and
palatal tooth surfaces, is increased in patients with
GERD’.8 This statement (statement no. 48) has been
approved with 98% of agreement among the Montreal
Group panelists and, reportedly, is based on a high
level of evidence, possibly the highest level of evi-
dence linking GERD with any extra-oesophageal clini-
cal manifestation.8 Thus, it is not surprising that some
authors have advocated that the examination of the
oral cavity, in search for ‘atypical’ DEs, should be an
integral part of the physical examination of the patient
with suspected GERD.9 On the other hand, other
authors have denied, at least in children, that DEs may
represent a relevant problem in GERD patients.10
The aim of this systematic review was to: (i) analyse
all the published reports dealing with the association
between DEs and GERD to define the size of the prob-
lem; (ii) verify the presumed pathophysiology and (iii)
highlight whether particular subgroups of population
can have an increased risk of DEs as a consequence of
GERD.
MATERIALS AND METHODS
The Medline database (from January 1966 to Septem-
ber 2007) and the Cochrane Controlled Trials Register
were searched. The search terms used were: dental ero-
sion AND gastro esophageal reflux OR esophagitis.
The only limits employed in this search were English
and Human studies. Review articles using the same
search terms were also sought to help identify addi-
tional original studies. A careful review of references
was conducted of all retrieved articles. Only studies
published in extenso were included. A data extraction
form was developed to standardize the methodological
and quantitative information that was extracted from
each study (available from authors on request). This
consisted of: inclusion criteria of patients in the study,
patient setting (gastrointestinal (GI) vs. dentistry clin-
ics, adult vs. children study), diagnosis of GERD (based
on symptoms alone, on upper endoscopy and ⁄ or pH
profile as well), study design, sample size, number of
dropouts, main outcome measures used to assess effi-
cacy and study conclusion. Each study was reviewed
at least by two authors.
RESULTS
The search (final date September 2007) resulted in 19
citations, eight of which were reviews. The Cochrane
search and the additional search through cross refer-
ences resulted in six more citations. This left a total of
17 eligible studies.9–24 Of these, five concerned the
children population10, 20–23 and the remaining the
adult one;9, 11–19 furthermore, one study24 was con-
ducted on a special population, i.e. institutionalized
intellectually disabled individuals.
Because of the marked variation in outcome mea-
sures (see Table 1), it was not possible to perform a
formal meta-analysis, that is a statistical pooling of
results. Instead, the results were analysed in a qualita-
tive fashion. In the following paragraphs, we will first
consider the results of studies conducted on adult pop-
ulations and subsequently those studies conducted on
paediatric patients and finally those conducted on spe-
cial populations (i.e. intellectually disabled).
ª 2008 The Authors, Aliment Pharmacol Ther 27, 1179–1186
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 Table 1. Characteristics of studies included in the review

Author (reference) Type of study No. of subjects, type of population Outcome variable

Munoz et al.11 Case–control 181 GERD patients, 72 HC DE: presence, severity, location.
Periodontal lesions.
Moazzez et al.13 Case–control 31 patients with extra-oesophageal GERD, 7 HC Proximal GER extension

Journal compilation ª 2008 Blackwell Publishing Ltd

Gregory-Head et al.14 Cross-sectional 20 patients with DE % of patients with GERD
Schroeder et al.9 Cross-sectional 12 patients with DE, 30 with GERD referred for 24-h pH % DE in GERD, % GERD in DE

ª 2008 The Authors, Aliment Pharmacol Ther 27, 1179–1186

Loffeld15 Retrospective inventory Patients with reflux oesophagitis No dental prosthesis, % damage of incisors
Jarvinen et al.16 Observational 44 patients with GERD ⁄ DU, 48 postcholecystectomy, % DE
17 with GU
Meurman et al.17 Observational 117 patients with GERD % DE
Bartlett et al.12 Observational 36 patients with DE, 10 HC Oesophageal pH profile
Myklebust et al.18 Questionnaire study General population DEs
Dahshan et al.20 Observational 37 children with possible GERD % DE
O’Sullivan et al.10 Observational 53 children with GERD % DEs
Linnett et al.21 Case–control 52 children with GERD history, 52 healthy sibling % DEs
Aine et al.22 Observational 15 children with GERD % DEs
Ersin et al.23 Case–control 38 children with GERD, 42 HC % DEs
Bohmer et al.24 Case–control Intellectually disabled % DEs, pH profile
Oginni et al.19 Case–control 125 GERD patients, 100 HC % DEs
Gudmundsson et al.25 Observational 14 patients with DE referred for dual 24-h pH Oesophageal and oral pH profile

GERD, gastro-oesophageal reflux disease; DE, dental erosion; DU, duodenal ulcer; GU, gastric ulcer; HC, healthy controls; 24-h pH, 24-hour oesophageal
pH-monitoring.
S Y S T E M A T I C R E V I E W : D E N T A L E R O S I O N S A N D G E R D 1181
1182 F . P A C E et al.

where a control group was used, such as, for example,

Studies conducted on adults
Overall, 11 original studies were found;9, 11–19, 25 of
these, seven were conducted on GERD patients (see
Table 2). Vice versa, studies by Bartlett et al.,12
Gregory-Head et al.14 and Gudmundsson et al.25 were
conducted on patients with DEs, to investigate the
presence of GERD (Table 3). The study by Myklebust
et al.18 is a questionnaire survey conducted in Norway,
but information on the dental status were provided by
the personal dentists only for a minority of respon-
dents, and therefore were not included in the further
analysis. Finally, the study by Schroeder et al.9 had
both a dental group, which was screened for GERD,
and a gastroenterological group, referred for dental
evaluation.
Dental erosions were found ranging between 5%
and 47.5%, with a median value of 32.5%, of the
GERD patient samples; the greatest prevalence was
found in studies defining GERD patients on the basis
of symptoms alone,11 whereas the lowest was found in
a study using endoscopic criteria.16 In those studies
the studies by Munoz et al.,11 Bartlett et al.,12 or Jarvi-
nen et al.16 the prevalence of DEs (or the DE score)
was statistically greater in GERD subjects than in con-
trols. No data regarding the prevalence of DEs were
provided by two studies, namely Moazzez et al.13 and
Gregory-Head et al.14 In the former, a score was
assessed of teeth with palatal tooth wear, where 0 rep-
resents no damage and four represents pulpal expo-
sure: it was found that the proportion of patients with
a score ‡2 was 70.8% vs. 0% in controls, the propor-
tion of those with score ‡3 was 8.3% vs. 0%, and none
had a score ‡4 in either group, whereas the pH-moni-
toring found a higher percentage of time spent in dis-
tal oesophagus with pH < 4 in GERD groups only for
the supine period. Interestingly, in this study, a signifi-
cant correlation was found between the proportion of
the total time with pharyngeal pH below 5.5 and the
proportion of teeth with palatal score 2 (r = 0.44) or 3
(r = 0.44), P < 0.01. In the study by Gregory-Head
et al.,14 the Tooth Wear Index (TWI) score was
assessed in GERD patients and in controls; it was

No. of patients GERD diagnostic Table 2. Prevalence of dental

Study (reference) with GERD method Prevalence (%) erosions in adults with
GERD (for abbreviations,
Munoz et al.11 181 Symptoms 47.5 see Table 1)
129 24-h pH-metry
78 Endoscopy
Moazzez et al.13 18 ⁄ 31 24-h dual pH-metry Not stated*
Schroeder et al. 20 ⁄ 30 24-h pH-metry 40
(GI group)9
Loffeld 15 293 Endoscopy 32.5
Jarvinen et al.16 35 Endoscopyà 5
Meurman et al.17 117 Symptoms 24
Oginni et al.19 125 Symptoms 16

* A dental erosion score was used: GERD patients higher score then non-GERD.
  Only the incisor teeth status was assessed.
à Endoscopic oesophagitis and duodenal ulcer were grouped together.

No. of patients Table 3. Prevalence of GERD

with dental Prevalence in adults patients with dental
Study (reference) erosions GERD diagnostic method (%) erosions (for abbreviations, see
Table 1)
Bartlett et al.12 36 24-h oesophageal pH-metry 64
Gregory-Head et al.14 20 24-h dual oesophageal pH-metry 50
Gudmundsson et al.25 14 24-h oesophageal pH-metry 21
Schroeder et al. 12 24-h oesophageal pH-metry 83
(dental group)9

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found that both the overall score and the maxillary
and mandibular surfaces of GERD subjects were signif-
icantly higher than those observed in controls: 0.953
vs. 0.298, 0.941 vs. 0.271 and 0.875 vs. 0.326, respec-
tively (P < 0.005), suggesting that a relationship exists
between loss of teeth structure, as measured by the
TWI score and the occurrence of GERD.
Studies conducted on children (Table 4)
A total of five studies were found.10, 20–23 In the study
by Dahshan et al.,20 37 children undergoing elective
upper endoscopy for possible GERD were evaluated for
the presence, severity and pattern of erosion and stage
of dentition of teeth. It was found that 24 of them had
GERD, 20 of whom had DEs as well, 10 with mild ero-
sion (tooth score £1), six with moderate erosion (at
least one tooth scored 2), and four with severe erosion
(at least one tooth scored 3) according to the four-
point score proposed by Aine et al.22
In the study by O’Sullivan et al.,10 53 children with
moderate to severe GERD as defined by pH monitor-
ing, were examined for DEs. No control group was
investigated.
Results showed that the prevalence of DE was low
when compared with the UK National Survey, with
only nine (17%) of children showing any sign of
erosion, and of these only one had erosion involving
dentine.
In the study by Linnett et al.,21 52 children with a
‘definitive’ history of GERD underwent a dental exami-
nation and were compared on an individual basis with
a healthy control sibling without GERD symptoms; the
prevalence of teeth erosion was found to be statisti-
cally higher in GERD subjects (14%) than in controls
(10%), P < 0.05. Furthermore, GERD subjects had ero-
sion in more permanent teeth compared with controls
(4% vs. 0.8%, P < 0.05), and more severe erosions.
Table 4. Prevalence of dental erosions in children with GERD (for abbreviations, see Table 1)
Study (reference) No. patients with GERD
Dahshan et al.20 24 ⁄ 37
O’Sullivan et al.10 53
Linnett et al.21 52
Aine et al.22 15
Ersin et al.23 38
NA, not applicable.
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S Y S T E M A T I C R E V I E W : D E N T A L E R O S I O N S A N D G E R D 1183
In the study by Aine et al.,22 17 children who
attended a university hospital paediatric outpatient
clinic for GERD and who were found to have a patho-
logical reflux at 24-h oesophageal pH monitoring were
submitted to dental examination, with teeth erosion
scored according to the previously quoted Aine Index
(from 0 to three); no control group was investigated.
Overall, two patients had score 0, two patients score 1,
six patients score 2 and seven patients score 3, sug-
gesting that only a minority of GERD patients had
intact teeth.
Finally, in the study by Ersin et al.,23 the effects
were investigated of GERD on DE vs. caries forma-
tion, on salivary function and on salivary microbio-
logical counts. Thirty-eight GERD patients with a
mean age of 6 1 ⁄ 2 years and 42 healthy children of
the same age and gender and social background
comprised the study group. All subjects answered a
detailed frequency questionnaire related to acidic
drinks, foods, and sugar consumption and underwent
a clinical dental examination. The caries experience
of the children was recorded according to World
Health Organization criteria, and erosions were scored
according to the Eccles and Jenkins grading scale.26
The children were also investigated for stimulated
salivary flow rate, buffer capacity, and salivary
mutans streptococci (MS), lactobacilli, and yeast colo-
nization. The results of this rather complicated study
are the following: the prevalence of DE and the sali-
vary yeast and MS colonization was found to be sig-
nificantly higher in GERD children than in healthy
subjects (P < .05); the caries experience, salivary flow
rate, buffering capacities of the children, and fre-
quency of acidic drinks, foods, and sugar consump-
tion were found to be similar in both groups. The
authors concluded that GERD children were at an
increased risk of developing erosion and caries com-
pared with healthy subjects.23
Age (range) GERD diagnostic method Prevalence (%)
2–18 years Endoscopy 83
2–16 years 24-h pH-metry 17
17 months–12 years Symptoms + histology 14
22 months–16 years Symptoms 87
6.5 years Symptoms NA
1184 F . P A C E et al.
Studies conducted on special groups
Only one such study was found, dealing with intellec-
tually disabled.24 In this study, authors argued that
not only GERD but also vomiting, rumination and
regurgitation are conditions more frequently encoun-
tered in the intellectually disabled population. There-
fore, they investigated the presence of DEs in
combination with GERD among intellectually disabled
inhabitants, arbitrarily defined as having an IQ < 50,
taken from three Dutch institutes. In their study, 63
individuals randomly selected underwent an oesopha-
geal pH test and dental screening, and possible predis-
posing and attributable factors were determined. They
defined an abnormal pH level as a pH < 4, >4.5% of
the measured time. Subjects with DEs were compared
with those without DEs. The results of this study
showed that in 29 of 63 (46.0%) cases, evidence of
DEs was found. In 19 of these 29 subjects with ero-
sions (65.5%), GERD was diagnosed, compared with
nine (26.5%) of 34 subjects without erosions
(P = 0.04). In the subjects with erosions, mean dura-
tion of pH <4 was 15.6% (range: 0.5–90.5) compared
with 6.3% (range 0–40.4) in subjects without erosions
(P = 0.02). An IQ <35 was found to be predisposing
(P < 0.001). Authors concluded that, in this population
of 63 institutionalized intellectually disabled persons,
DEs were diagnosed in 46% and that 65% of them had
GERD. Individuals with longer duration of pH < 4 than
6.3% of the measured time and with an IQ < 35 were
at higher risk to develop DEs.24 This study shows that
DEs in the intellectually disabled population might be
an oral manifestation of GERD.
DISCUSSION
The variety of extra-oesophageal manifestations of
GERD is incompletely appreciated. This may be
because of many factors, including the uncertainty in
classification of GERD patients, and in particular, of
patients with typical GERD symptoms but absence of
oesophagitis.
Consequently, the published estimates of extra-
oesophageal disorders vary widely27–31 and symptoms
other than heartburn and regurgitation are reported in
up to 50% of patients with endoscopically proven
reflux oesophagitis.32 Nevertheless, for some of the
proposed associated manifestations, the evidence link-
ing them with GERD is robust, whereas that for the
other is less impressive. As an example, the recent
novel definition and classification of GERD, referred to
as the Montreal global classification, strongly suggested
causality between reflux and cough, laryngitis, asthma,
and DEs, although recognizing the rarity of extra-
oesophageal syndromes occurring in isolation without
a concomitant manifestations of the typical oesopha-
geal syndrome. Furthermore, it emphasizes the fact that
these syndromes are usually multifactorial, with GERD
acting as one potential aggravating cofactor.8 For other
syndromes, such as sinusitis, pulmonary fibrosis,
pharyngitis, or recurrent otitis media, the Montreal
Working team concluded that adequate evidence of
causal linkage is lacking.8 Among the sufficiently
proven positive associations with GERD, DE was found
to be a clear-cut one. Studies since the early 1970s7
have highlighted the injurious role of gastro-duodenal
contents in oral soft-tissue pathology as well as DEs.
The studies we have reviewed are based on a hetero-
geneous definition of GERD, which is, in some cases,
obtained by the demonstration of endoscopic oeso-
phagitis,11, 15, 16 in others by a pathological pH
metry9, 11–14, 25 or by the presence of GERD symp-
toms.11, 17, 19 They confirm an prevalence of DEs in
adult GERD patients, which is, on average, higher
(median value 50%) than that observed in the general
population (Table 2), where it is estimated to be as high
as 5%.2 As far as the paediatric population is con-
cerned, we found the prevalence extremely variable,
with a range between 13 and 87%, according to the
method used to diagnose GERD. Finally, we explored
the other way round, i.e. the prevalence of GERD in
patients with DEs, and found an observed prevalence
ranging from 21 to 83%, depending on the method
used to diagnose GERD (Table 3). Finally, we found a
study indicating that intellectually disabled people are
at particularly high risk for developing DEs.24
As far as the third aim of our systematic review is
concerned, i.e. the pathophysiology of DEs in patients
with GERD, a majority of studies here reviewed con-
firm that DEs may be because of acid reflux damage,
while on the contrary, dental caries appear to be unre-
lated or conversely related to GERD;11 in one study, it
is even suggested that acid reflux may play a role in
preventing the formation of dental caries by inhibiting
bacterial growth in the mouth.9 In general, DE appears
to be a multi-factorial phenomenon in which the pro-
tective buffering capacity of the oral cavity is over-
come by either reduced salivary secretion or increased
volume of injurious gastric refluxate. Although GERD
may have a noxious effect on other oral structures, it
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 S Y S T E M A T I C R E V I E W : D E N T A L E R O S I O N S A N D G E R D 1185

appears to be the most prevalent injury.4 The site of
teeth involvement may be universal, but the most
commonly seen damage occurs on the facial, occlusal,
and lingual surfaces. The severity of DEs – according
to the Eccles and Jenkins26 classification – appears to
be correlated with the duration and severity of reflux
symptoms.17, 19 While a majority of patients (‡60%)
with DE and GERD report typical GERD symptoms, no
association has been found between severity of reflux
symptoms and subjective symptoms in the mouth.17 A
relationship has also been found between the severity
of DEs and the severity of oesophageal acid exposure
as measured by pH-metry; in the study by Schroeder
et al.9 conducted in adults, the cumulative erosion
score correlated with proximal upright reflux (r =
0.55, P < 0.01), but this association was not found in
the study by Munoz et al.11 or not specifically sought
in the study by Moazzez et al.,13 Gregory-Head
et al.,14 Gudmundsson et al.25 among the studies con-
ducted in adults and by O’Sullivan et al.10 among the
ones conducted in children. In the study by Bartlett
et al.,12 the relationship was found between percentage
of time with distal oesophagus pH <4 and oral acid
exposure time <6 as measured by oral pH-metry, and
between the latter and the severity of DE.
The injurious effect of acidic juice of extrinsic
(citric fruits and acidic beverages) or intrinsic origin
(gastro-oesophageal reflux (GER)) on the teeth and
oral tissues has been extensively studied.2, 12, 17 The
direct contact of acid is considered to be the main
mechanism of injury; GER can result in dental injury
by the dissolving of the inorganic material of the
teeth (hydroxyapatite crystals in enamel), which
occurs below the critical pH level of 5.5.25 This leads
to DE, an irreversible loss of tooth substance without
bacterial involvement,9 which may be encountered at
different stages, from the very early stages, where the
only sign may be a barely noticeable loss of surface
lustre evident on a clean, dry enamel to the typical
yellowish areas on the surface of the tooth, because
of the exposition of the underlying dentine through
the thinned overlying enamel.1 DE predisposes the
teeth to attrition (flattening of occlusal surface) and
abrasion (wearing away of teeth substance), which
can lead to tooth loss, cosmetic disfigurement and
altered facial appearance.33
In conclusion, from a practical point of view, as DE
is the predominant oral manifestation of GERD and is
highly prevalent in the general population, dental
examination plays an important role in the evaluation
of patients with typical and atypical symptoms of
GERD and in the above categories of patients. DE
might be easily diagnosed by primary care physicians
and gastroenterologists who are familiar with its phys-
ical characteristics. Early diagnosis and suppression of
refluxed acid through lifestyle changes and medica-
tions have been reported to prevent further damage
and tooth loss potentially.33 For patients with signs of
erosion, a dental referral is appropriate for evaluation
and restoration of lost tooth structure and institution
of preventive dental measures. Thus, not only is it
important for the dentist to be familiar with and
inquire about typical and atypical reflux symptoms,
but also the primary care physician and the gastroen-
terologist need to pay more attention to the often
neglected oral examination.
ACKNOWLEDGEMENT
Declaration of personal and funding interests: None.

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