J Oral Pathol Med (2008) 37: 336–340
ª 2008 The Authors. Journal compilation ª 2008 Blackwell Munksgaard Æ All rights reserved
www.blackwellmunksgaard.com/jopm
Oral manifestations in patients with gastro-oesophageal
reflux disease: a single-center case–control study
Olga Di Fede1, Chiara Di Liberto1, Giuseppe Occhipinti1, Sergio Vigneri2, Lucio Lo Russo3, Stefano Fedele4,
Lorenzo Lo Muzio3, Giuseppina Campisi1
1
Department of Oral Sciences, Faculty of Medicine, School of Dentistry, Oral Medicine Section, University of Palermo, Palermo,
Italy; 2Institute of Internal Medicine and Geriatrics, Section of Gastroenterology, University of Palermo, Palermo, Italy; 3Department
of Surgical Sciences, Faculty of Medicine, School of Dentistry, University of Foggia, Foggia, Italy; 4University College of London,
Eastman Dental Institute, Oral Medicine Unit, London, UK
OBJECTIVE: To assess the occurrence of oral patholog-
ical changes and symptoms in patients affected by gastro-
oesophageal reflux disease (GERD).
PATIENTS AND METHODS: 200 patients with GERD
and 100 matched healthy controls were studied. Thor-
ough visual examination of the dental and oral mucosal
tissues was performed and medical history relevant to
oral symptoms was collected. The primary outcome was
defined as a statistically significant difference, between
the study group and controls, in the presence of the fol-
lowing indicators: soft ⁄ hard palate and uvula erythema,
tooth wear, xerostomia, oral acid ⁄ burning sensation,
subjective halitosis and dental sensitivity. Statistical
analysis included chi-squared test, and crude odds ratio
with 95% % CI.
RESULTS: Univariate analysis showed that xerostomia,
oral acid ⁄ burning sensation, subjective halitosis, and soft
and hard palate mucosa and uvula erythema were more
common in patients with GERD than matched controls
(P < 0.05).
CONCLUSIONS: This study failed to find any significant
association between GERD and dental erosions, whereas
some symptoms and other objective oral mucosal chan-
ges were found to be significantly associated with GERD.
J Oral Pathol Med (2008) 37: 336–340
Keywords: dental erosion; gastro-oesophageal reflux disease;
oral manifestations; oral mucosa lesions
Introduction
Gastro-oesophageal reflux disease (GERD) refers to
reflux of gastric contents into the oesophagus leading to
oesophagitis, reflux symptoms capable to impair quality
Correspondence: Prof. Giuseppina Campisi, Via del Vespro 129,
90127 Palermo, Italy. Tel ⁄ Fax: +39 091 6552236, E-mail: campisi@
odonto.unipa.it
Accepted for publication September 25, 2007
doi: 10.1111/j.1600-0714.2008.00646.x
of life, or long-term complications (1, 2). Heartburn and
regurgitation are the typical clinical manifestations of
GERD; in addition, several pulmonary, ear, nose and
throat and oral cavity manifestations have been linked
to GERD. These have been termed extra-oesophageal
manifestations of GERD (3) and include symptoms
such as dysphagia, odynophagia, globus (lump in the
throat), sore throat, laryngitis, water brash (increased
salivary flow) and cough, among many others (2, 3).
With regard to GERD-associated manifestations in the
oral cavity, dental erosions, halitosis, non-specific
burning sensation, mucosal ulceration ⁄ erosion, loss of
taste and both xerostomia and increased salivary flow
have been reported (4). However, most studies focused
on dental involvement only (5–43), whereas patholog-
ical changes of the soft oral tissues and salivary flow
have been less frequently investigated (7, 44–48). The
aim of this study was to assess the occurrence of oral
manifestations in a population of patients affected by
GERD.
Patients and methods
This case–control study was conducted at the Depart-
ments of Oral Medicine and Gastroenterology of
Palermo University Hospital, Italy. The study group
(S) consisted of 200 patients with GERD. Eighty-nine
(44.5%) were men (mean age: 46.9; range: 19–78) and
111 (55.5%) were women (mean age: 49.3; range: 19–
78). The control group (C) included 100 healthy
subjects, without any symptoms or medical history of
GERD or other gastrointestinal diseases. They were
recruited from teachers of secondary schools, and from
medical students. Forty-six (46.0%) were men (mean
age: 43.5; range: 20–78) and 54 (54.0%) were women
(mean age: 49.1; range: 20–78). S and C groups
were matched for demographic variables (P > 0.2 by
Student’s t-test); in addition, diet, particularly in rela-
tion to weekly acidic beverages ⁄ foods consumption, was
comparable between the two groups, as found by history

collection. Patient informed consent and ethical
approval were obtained.
Diagnosis of GERD
All patients of the study group were new patients seen at
the Gastroenterology Department because of symp-
toms ⁄ signs suspicious of GERD. Gastro-oesophageal
reflux disease was diagnosed by (i) oesophago-gastro-
duodenoscopy (EGDS), (ii) 24-h oesophageal pH-metry.
Biopsy of oesophageal mucosa was taken in case EGDS
had showed oesophagitis (according to LA classifica-
tion; 49). If Helicobacter pylori infection was suspected,
gastric and duodenal biopsies were taken and specimens
were tested with Rapid Urease Test. In our series all
patients reported that they had never received regularly
drugs to treat GERD.
Oral involvement assessment
Medical history of potential oral symptoms associated
with GERD was carefully collected. The pres-
ence ⁄ absence of the following parameters was evalu-
ated: xerostomia, oral acid ⁄ burning sensation,
subjective halitosis and dental sensitivity. A thorough
oral and dental examination was performed in both
groups and the presence ⁄ absence of the following
indicators was evaluated: soft ⁄ hard palate and uvula
erythema and dental erosion (tooth wear).
Xerostomia, defined as a subjective feeling of dry
mouth, was assessed by clinical history collection, using
standardized questions taken from the questionnaire
developed by Field et al. (50); in particular, were used
the following questions belonging to the oral symptoms
and oral symptoms control domain: (i) Do you feel your
mouth is dry?; (ii) Do you have difficulty eating certain
foods?; (iii) Do you have difficulty swallowing certain
foods?; (iv) Do you use water to help when swallowing
certain foods?; and (v) Do you use water to rinse away
debris? In subjects with xerostomia a positive answer
was expected for the first question; the remaining
questions were used to exclude the presence of an
objective dysfunction.
Dental sensitivity was defined as an uncomfortable
dental sensation elicited by temperature variations of
beverages ⁄ foods, by particular beverages ⁄ foods or sim-
ply by air while breathing.
Gastro-oesophageal reflux disease-related soft ⁄ hard
palate erythema was defined as an area of erythema
affecting the mucosa of soft palate, the uvula and ⁄ or the
hard palate which could not be characterized clinically as
any other disease (e.g. candidosis and blistering disease).
Gastro-oesophageal reflux disease-related dental ero-
sion was defined as loss of tooth substance by a chemical
process that does not involve bacteria or unusual ⁄ exces-
sive dietary habits or other occupational substances (e.g.
acidic foodstuffs, beverages, snacks and exposure to
acidic contaminants in the workplace such as aero-
solized industrial acids in lead battery factories; 10).
Loss of dental structure because of abnormal attrition
(clenching or bruxing of one tooth surface against
another; physical wear by extraneous objects such as
toothbrushes), also known as tooth abrasion, was
Oral manifestations of GERD
Di Fede et al.
337
excluded on the basis of clinical features and patient
history (51). Thus, dental erosion was assessed in all the
patients and controls by a single investigator under ideal
lighting conditions, and to standardize this evaluation,
patients and controls were assigned a Tooth Wear Index
score (TWI), using the protocol developed by Smith and
Knight (52). The TWI utilizes a numerical scale to
indicate clinical levels of tooth structure loss and ranges
from no loss of any surface characteristics (score 0) to
complete loss of enamel with exposure of secondary
dentin or pulp chambers (score 4). Cervical buc-
cal ⁄ labial, occlusal ⁄ incisal and palatal ⁄ lingual surfaces
of all teeth was evaluated and assigned a score; a total
TWI score (sum of scores for every surface of every
tooth score) and a mean total TWI score (total TWI
score divided by the number of examined surfaces) was
then calculated for each subject. The subject was
considered to be positive for dental erosion for any
mean total TWI > 0.
Statistics
All data, including digital photographs, were organized
on a computerized table. Result variables were
subdivided into the following homogeneous groups: (i)
socio-demographical variables (age, gender), (ii)
GERD-related symptoms (xerostomia, oral acid-burn-
ing sensation, dental sensitivity and halitosis) and (iii)
oral signs (tooth wear ⁄ dental erosion, soft ⁄ hard palate
and uvula mucosal erythema). Statistical analysis of all
variables and their relationships was performed by
means of the SPSS 10.5 software (Chicago, IL, USA).
As univariate analysis, v2 test was used to evaluate
statistically significant differences between the categor-
ical variables. Only P-values <0.05 were considered
statistically significant. The crude odds ratio and its
corresponding 95% confidence intervals were calculated
to estimate the level of association.
Results
As regards primary endpoint, univariate analysis
showed that xerostomia, oral acid ⁄ burning sensation,
subjective halitosis and soft ⁄ hard palate and uvula
mucosal erythema (Fig. 1) were significantly associated
with GERD (Table 1). Xerostomia was recorded in
54.5% and 29.0% of patients with GERD and healthy
subjects respectively. Oral acid ⁄ burning sensation was
reported by 43.2% of S patients in comparison with the
21.0% of C patients. Halitosis was found in 49.2% of
patients with GERD and 31.0% of healthy subjects
(P < 0.05).
On the contrary, no significant association was found
between tooth wear, dental sensitivity and GERD
(P > 0.2).
Discussion
Present results show that xerostomia, oral acid ⁄ burning
sensation and halitosis are the most frequent symptoms
associated with GERD. This is in accordance with
previous studies (46, 53, 54). However, halitosis has
J Oral Pathol Med
 Oral manifestations of GERD
Di Fede et al.

338
Table 2 Variability in the prevalence of dental erosion in different
gastro-oesophageal reflux disease populations

Prevalence of
Study Year dental erosion (%)
Benages et al. (73) 2006 47.5
Moazzez et al. (14) 2004 23.8
Munoz et al. (74) 2003 47.5
Dahshan et al. (23) 2002 83.3a
Silva et al. (7) 2001 3.2
Bartlett et al. (28) 1996 66.0
Loffeld et al. (64) 1996 68.0
Schroeder et al. (10) 1995 40.0
Meurman et al. (15) 1994 24.0
Jarvinen et al. (46) 1988 20.0
a
Paediatric patients.

as any other disease on soft and hard palate mucosa and

Figure 1 Erythema of soft palate and uvula in a patient affected by
gastro-oesophageal reflux disease.
been rarely reported in association with GERD (55)
because of its impact on quality of life it should be taken
into account in clinical practice and carefully addressed
in future research.
The occurrence of xerostomia in patients with GERD
has been already studied but results have been often
controversial. As a subjective feeling of oral dryness its
definition is strictly related to saliva. Saliva is considered
one of the major protective mechanisms of oesophageal
mucosa against gastric reflux and qualitative (e.g.
deficiency of salivary growth factor and cytokines) and
quantitative (e.g. hyposalivation) abnormalities have
been linked to GERD pathogenesis (56–59), teeth health
and dental erosion (60). In this study, we have chosen to
investigate the symptom xerostomia as in an our
preliminary study (unpublished data) focusing on sali-
vary modifications in the reported group of patients and
controls we found no statistical significant differences in
basal salivary flow between the two groups. Thus,
according to the present results, xerostomia may well be
included within GERD extra-oesophageal symptom-
atology because its pathogenesis appears disconnected
from basal saliva production.
As regards clinical signs, 21.5% of our patients with
GERD vs. 5.0% of healthy subjects showed erythema-
tous lesions which could not be characterized clinically
uvula; these lesions are typically recognized as soft tissue
lesions related to GERD (46, 53, 54) and caused by the
direct offending action of refluxed acid.
The frequency of dental erosion (any mean total
TWI > 0) resulted markedly lower with respect to
previous studies (Table 2). Only 9.0% of patients with
GERD presented these lesions, in comparison with
13.0% of healthy subjects and the difference was not
statistically significant. However, no clear definitive data
are available regarding the real prevalence of dental
erosion in patients with GERD and prevalence varies
widely among different studies. This can be explained by
several factors such as frequency of regurgitation,
duration of untreated disease, buffering properties of
saliva (61–66), diet (67), friction caused by tongue on
teeth during mastication, deglutition and phonation (28,
46, 53) and the eventual presence of dental restorations.
In addition, available studies are generally small,
description of diagnostic criteria is often not available
(7, 14, 21, 25, 68–78), indices used are not comparable,
and the study outcomes are frequently confounded by
the inclusion of patients on antireflux therapy (long-
term exposure of dental tissues to gastric acid is
considered a key factor in the formation of dental
erosion; 44, 79, 80). It is likely that a significant portion
of cases reported in the literature actually consisted of
patients with a particularly abundant reflux or unre-
sponsive to pharmacological therapy.
In addition, we found that dental hypersensitivity was
present in both S and C group at the same prevalence

Table 1 Oral manifestations in S and C group of patients

S group C group
[n = 200; n (%)] [n = 100; n (%)] OR (95 % CI) P-value
Xerostomia 109 (54.5) 29 (29.0) 2.9326 (1.7543–4.9024) <0.0001
Acid ⁄ burning sensation 86 (43.2) 21 (21.0) 2.8379 (1.6264–4.9519) 0.0009
Halitosis 98 (49.2) 31 (31.0) 2.1385 (1.2888–3.5485) 0.0004
Soft ⁄ hard palate and uvula erythema 43 (21.5) 5 (5.0) 5.2038 (1.9915–13.5976) 0.0002
Dental sensitivity 65 (32.5) 32 (32.0) 1.0231 (0.612–1.7104) n.s.
Tooth wear (any TWI > 0) 18 (9.0) 13 (13.0) 0.6162 (0.2882–1.3175) n.s.

n.s., not significant.

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339
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