By Nancy W. Burkhart, BSDH, EdD
Your new patient today is Rodney. He is 47 years old and has come to your clinic because he says “his teeth need to be cleaned.” He says that he probably needs some additional dental work completed (see Figure 1) since he began some restorative work with his previous dental providers. He is complaining of sensitivity and a constant bad taste.
|Figure 1: Male patient exhibits severe erosion on all maxillary facial surfaces and extensive lingual erosion. Patient was subsequently diagnosed with severe long-term GERD.|
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As you review his medical history, he states that he has decreased his use of over-the-counter antacids after taking them several times a day for a period of at least 10 years. As you begin your examination, you note the erosion on most surfaces of his teeth.
Two possibilities are considered. The first consideration is an eating disorder, and this type of erosion usually is found on the lingual surfaces of the teeth. But the patient denies any problem with disordered eating now or in the past.
The second consideration would be chronic long-term gastroesophageal reflux disease (GERD). After referral and diagnosis, Rodney does indeed suffer the effects of GERD. After many years of this chronic disease, the sensitivity/burning may actually decrease as the tissue becomes damaged, affecting the sensitive fibers, and this has occurred in Rodney’s case.
The use of antacids continues to increase in the United States. It is commonplace to hear that patients are using these medications to combat heartburn. Koufman (2011) reported results in a research study on acid reflux and wrote about the “acidification of the American diet.” Food that our great, great grandparents ate is very different in comparison to the fast food epidemic we see in the United States today. Koufman states that younger people are being treated today with disease states that once were found in middle age and the elderly populations. Koufman writes that serious changes have occurred in our diets within the past 50 years. She points out several common products such as the increased consumption of carbonated beverages that are highly acidic and high-fructose corn syrup, as well as saturated fats. Canned and bottled foods contain acid additives and many more chemicals have been used in growing, preserving, and processing foods in general.
The dental practitioner is in a prime position to question what is seen clinically and evaluate symptoms such as erosion, taste changes (sour taste) and suggest the need for referral and further examination with medical specialists.
Adenocarcinoma of the esophagus is usually preceded by a chronic condition called Barrett’s esophagus. The persistent exposure of the cells lining the esophagus result in what is termed Barrett’s metaplasia. Metaplasia occurs when the lining of esophageal mucosa exhibits cellular change from squamous epithelium to columnar cells in an adaptive attempt by the host to protect itself from the acid environment. This columnar epithelium can develop dysplasia leading to adenocarcinoma.
More than 3 million Americans are now living with Barrett’s esophagus. The increase has been correlated with, among other issues, the rise in obesity. Even small weight losses result in some improvement of the symptoms. Esophageal cancer is three to four times more common in men than in women, and the age in which most esophageal cancer is discovered is between ages 55 and 85 years old. Diagnosis usually occurs in the late stages, making survival rates decline. Recent SEER data estimates that 17,460 men and women (13,950 men and 3,510 women) will be diagnosed with — and 15,070 men and women will die of — cancer of the esophagus in 2012.
In past decades, squamous cell carcinoma was the most diagnosed type of cancer in the Western world; however, in recent years, adenocarcinoma has continued to increase and is now the most diagnosed form of esophageal cancer, accounting for 80% to 90% of esophageal cancer. More of the squamous type carcinoma occurs in South Central Asia, but there are high rates worldwide.
The squamous cells that line the esophagus are affected by acid and these cancers are usually found in the upper and middle part of the esophagus. The early stage of tissue destruction usually has few signs. Contributing factors include alcohol and tobacco as well. Studies related to laryngopharyngeal reflux disease (Johnston et al. 2004) detected pepsin (an enzyme found in gastric juice) present in the laryngeal epithelium of a group of patients with a decrease in CA-111 enzyme. CA-111 is a factor enabling cells to produce sufficient bicarbonate to neutralize gastric acid. The entire structure of esophageal and laryngopharyngeal areas is affected by chronic reflux. Smokeless tobacco, snuff, and betel quid use expose the tissues to product contact and residue of the products, and they increase the risk of oral cancers.
The second type of esophageal cancer is adenocarcinoma, and this is the most common type in the United States and Western Europe. This type of cancer is one of increasing concern. These cancers occur in the lower part of the esophagus and at the junction of the stomach called the gastroesophageal (GE) junction. Most cases of this type of cancer usually involve acid reflux disease. Risk factors for these cancers include obesity, hiatal hernia, Barrett’s esophagus, and alcohol and tobacco use. Hard liquor such as vodka, whiskey, and rum are most destructive to delicate tissues.
Proton pump inhibitor use has greatly increased in the United States during the past several decades, and over-the-counter antacids are widely used and have become a part of the American culture. Some of the brand names of the more common proton pump inhibitors in the United States are Nexium, Prevacid, Prilosec, Zegerid, Protonix, and Aciphex with generic names ending in prazole. The more common brand names of the early over-the-counter type H2 blockers (sometimes used in addition to or instead of PPIs) are Tagamet, Pepcid, and Zantac. More commonly used for occasional acid are Tums, Rolaids, and Maalox.
Additionally, Stein (2012) suggests that clinicians be aware of herbal remedies that the patient may list on a health history such as aloe vera juice, herbal licorice root, or betaine HCL since these are probably being used for acid reflux symptoms. Concerns exist about the long-term use of PPIs and the incidence of drug interactions.
Clopidogrel (Plavix) discourages clot formation in heart patients but becomes less efficient when taken with omeprazole, according to some reports. The enzyme CYP2C19 is inhibited (Harvard Newsletter, April 2011). Other studies, suggest taking the medications at separate times to avoid this problem. Additional risk factors associated with PPIs include fractures, C. difficile risk, iron and B12 deficiency, and pneumonia, especially when PPIs are used long term. Stomach acids are needed to keep organisms at optimal levels and for absorption purposes. The risk-benefit must be weighed for each individual.
Diagnosis: A procedure called upper endoscopy is performed to view the esophagus. A flexible tube with a light and camera on the end make videos and images available. Some patients have this procedure performed at the same time that their colonoscopy is scheduled so that everything is accomplished in one appointment. Patients diagnosed with Barrett’s esophagus may have no noted symptoms, or they may have no noticeable heartburn related complaints.
Researchers from the University of Pittsburgh (Nason et al. 2011) published results on 769 patients who received their first endoscopy. Of the patient population, 122 were diagnosed with adenocarcinoma. Patients who were adequately managing their GERD symptoms with proton pump inhibitors were 61.5% to 81.5% more likely to have Barrett’s esophagus or adenocarcinoma if they reported no symptoms compared to patients taking PPIs who reported severe symptoms. The study was recently published in Archives of Surgery suggesting that patients with mild or no symptoms of GERD are at a higher risk for developing esophageal cancer than those with severe GERD. It is thought that damage occurs to the lining of the esophagus, and that the burning sensation lessens due to long-term damage in the esophagus, resulting in less physical symptoms. Additionally, the patient is less likely to seek assistance and to be screened for damage when there is no discomfort.
Another interesting fact from the research was that long-term use of PPIs does not solve the existing problems, but may create additional complications. Problems such as calcium malabsorption may occur. This is a major issue in women, and especially menopausal women, who may already exhibit depletion of calcium in their bones leading to severe osteopenia or to osteoporosis. PPIs may cause the patient to be asymptomatic in the face of continued esophageal damage.
Many patients continue to eat acidic foods, consume alcohol and make no changes in lifestyle factors. The researchers conclude that early detection before severe damage has occurred is the optimal goal in order to avoid these complications and side effects.
Treatment: Cryoblation, radio frequency ablation, and surgical procedures that actually shave off early cell changes are treatments of choice when high-grade dysplastic Barrett’s or stage 1 esophageal cancer is diagnosed. Early diagnosis is crucial to prevent further damage to the tissues.
When patients exhibit erosion, clearing of the throat, take antacids on a regular basis, complain of indigestion or heartburn, or report a sour taste in their mouth or sore throat, a red flag should go up and get the dental professional’s attention that GERD/esophageal damage is a possibility. Suggesting that the patient see their physician, an ENT specialist, or a gastroenterologist is warranted. Having the available literature on hand to give to the patient could be life-saving information. As dental professionals, we not only note problems that we see orally, we need to assess other signs/symptoms that may indicate the possibility of disease states occurring elsewhere in the body. Early diagnosis and treatment should be the goal in total health.
As always, keep asking good questions and always listen to your patients. RDH
Appelman HD, Umar A, Orlando RC, Sontag SJ, Nandurkar S, El-Zimaity H, Lanas A, Parise P, Lambert R, Shields HM. Barrett’s esophagus: natural history. Ann. N.Y. Acad Sci. 1232. 2011; 292-308.
Johnston N, Knight J, Dettmar PW, Lively MO, Koufman J. Pepsin and carbonic anhydrase isoenzyme lll as diagnostic markers for laryngopharyngeal reflux disease. Laryngoscope. 2004;114:2129-2134.
Koufman JA. Low-acid diet for recalcitrant laryngopharyngeal reflux: therapeutic benefits and their implications. Annals of Otology, Rhinology & Laryngology. 2011;120(5):281-287.
Luketich JD, Pennathur A, Awais O, Levy RM, Keeley S, Shende M, Christie NA, Weksler B, Landreneau RJ, Abbas G, Schuchert MJ, Nason KS. Outcomes after minimally invasive esophagectomy: review of over 1,000 patients. Ann Surg. 2012;256(1):95-103.
Nason KS, Wichienkuer PP, Awais O, Schuchert MJ, Luketich JD, O’Rourke RW, Hunter JG, Morris CD, Jobe BA. Gastroesophageal reflux disease symptom severity, proton pump inhibitor use, and esophageal carcinogenesis. Arch Surg. 2011; 146(7):851-8.
Proton–pump inhibitors: Harvard Health Publications, Harvard Medical School. http://www.health.harvard.edu/newsletters/Harvard_Health_Letter/2011/April/proton-pump-inhibitors.
Stein JM. A state of flux. RDH, September 2012;32-9:124-125.
U.S. National Cancer Institute. Surveillance Epidemiology and End Results. http://seer.cancer.gov/statfacts/html/esoph.html. Accessed October 1, 2012.
NANCY W. BURKHART, BSDH, EdD, is an adjunct associate professor in the department of periodontics, Baylor College of Dentistry and the Texas A & M Health Science Center, Dallas. Dr. Burkhart is founder and cohost of the International Oral Lichen Planus Support Group (http://bcdwp.web.tamhsc.edu/iolpdallas/) and coauthor of General and Oral Pathology for the Dental Hygienist. She was a 2006 Crest/ADHA award winner. She is a 2012 Mentor of Distinction through Philips Oral Healthcare and Pennwell Corp. Her website for seminars on mucosal diseases, oral cancer, and oral pathology topics is www.nancywburkhart.com.
Signs Of Esophageal Damage May Include
- Difficulty or painful swallowing
- Weight loss
- Blood in the stool
- Loss of appetite
- Feeling of fatigue
- Pain in the throat or back
- Hoarseness or change in voice
- Nausea after eating
- Sour taste in mouth
- Sore throat
- Feeling that food is stuck behind the breastbone
- Heartburn or burning in the chest/past or present
- A family history of Barrett’s esophagus or esophageal cancer
- Belching or burping excessively
- Throat clearing
In the cases of GERD, symptoms are:
- Most likely to occur at night or may be worse at night
- Increase by bending, stooping, lying down, or eating
- Temporarily relieved by antacids
The Esophageal Cancer Action Network
A guide for patients may be downloaded at www.ecan.org (www.ecan.org/site/PageNavigator/Patient_Guide.html).The guide is available as a free download from the ECAN website and limited quantities of printed guides are distributed at events such as health fairs.
ECAN, a national nonprofit network raises awareness about the link between heartburn and cancer. The patient guide was created with the participation of more than 100 doctors across the United States. The guide provides information for initiating discussions with primary care physicians regarding screening for esophageal cancer. Upon request, ECAN will provide doctors informational cards to display and distribute to patients; the cards include both a web address and a QR code for access to the free download. To request informational cards, email ECAN at firstname.lastname@example.org.
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