Abstract. Gastroesophageal reflux disease (GERD) is an established, non-carious etiology of dental erosion. Retrograde exposure of the dentition to gastric acid lowers intraoral pH below the critical threshold for enamel dissolution (approximately pH 5.5), producing a characteristic pattern of tooth surface loss distinct from caries or mechanical wear. Pooled prevalence estimates indicate that roughly one in four to one in three adults with GERD exhibit dental erosion, and children with GERD carry a substantially elevated odds of enamel erosion relative to unaffected peers. Diagnosis relies on recognition of characteristic erosion patterns, most often on palatal and occlusal surfaces, combined with validated indices such as the Basic Erosive Wear Examination (BEWE). Management is multidisciplinary, combining medical control of reflux with preventive and restorative dental measures. This review summarizes current evidence on the epidemiology, etiology, diagnosis, and management of GERD-associated dental erosion.
Epidemiology
Systematic reviews consistently demonstrate a bidirectional association between GERD and dental erosion. Marsicano et al. reviewed epidemiological surveys and found substantial variability in reported prevalence, with dental erosion identified in a median of roughly 24% of GERD patients (range 5 to 48%) across studies, while the median prevalence of GERD among patients presenting with dental erosion was approximately 32.5% in adults (range 21 to 83%) [1]. In the pediatric population, a 2022 systematic review and meta-analysis by Li et al. pooling data across multiple studies found that children with GERD had significantly elevated odds of enamel erosion compared with children without GERD, with a pooled odds ratio near 4.5 [2]. Heterogeneity in GERD case definitions (symptom-based versus pH-monitoring-confirmed) and in erosion scoring indices across the literature limits precise pooled estimates, but the direction and consistency of the association across study designs support a genuine clinical relationship [1,3].
Etiology and Pathogenesis
Dental erosion is a chemical, non-bacterial process defined as irreversible loss of dental hard tissue by acid dissolution in the absence of bacterial involvement, distinguishing it from caries. In GERD, retrograde flow of gastric contents (pH often below 2) into the oral cavity lowers local pH below the critical value for hydroxyapatite dissolution, softening and progressively dissolving enamel and, with continued exposure, dentin [3]. Nocturnal reflux is disproportionately damaging because supine positioning facilitates acid transit and because salivary flow, the principal physiologic buffer and clearance mechanism, is markedly reduced during sleep. Reduced salivary flow or buffering capacity, whether from GERD-related changes or a coexisting xerostomic condition, compounds the erosive burden by prolonging acid contact time and limiting remineralization between exposures [1,3]. The classic distribution of GERD-associated erosion involves the palatal (lingual) surfaces of the maxillary anterior teeth and the occlusal surfaces of posterior teeth, reflecting the pattern of acid pooling and contact during reflux episodes, in contrast to extrinsic dietary erosion, which more often affects labial and buccal surfaces.
Diagnosis
Clinical diagnosis relies on recognition of erosion morphology (smooth, glazed, or concave surfaces without the ditching characteristic of abrasion, and cupping of cusp tips without associated plaque or caries) correlated with a history of reflux symptoms or a confirmed GERD diagnosis. The Basic Erosive Wear Examination (BEWE), introduced by Bartlett, Ganss, and Lussi, provides a standardized, sextant-based scoring system (0 = no erosive loss to 3 = loss exceeding 50% of the surface) that sums to a cumulative risk score used to guide the intensity of management, from monitoring at low scores to active intervention at high cumulative scores [4]. Because erosion can precede a formal GERD diagnosis, dental identification of a reflux-consistent pattern, particularly in patients without other clear extrinsic acid exposure, can prompt referral for gastroenterological evaluation.
Management
Management is necessarily multidisciplinary. Medical control of reflux, whether through lifestyle modification, acid-suppressing medication, or, when indicated, surgical management, reduces the frequency and severity of acid exposure and is foundational to halting progression [1,3]. Dental management is risk-stratified: patients with low BEWE scores are managed with dietary and behavioral counseling (avoiding toothbrushing immediately after reflux or emesis, since acid-softened enamel is more susceptible to abrasive loss), topical fluoride, and remineralizing agents. A 2025 randomized clinical trial by Scribante et al. found that remineralizing treatments, including fluoride and biomimetic agents, produced measurable improvements in dentin hypersensitivity and erosion-related outcomes in GERD patients over a defined follow-up period, supporting their use as first-line preventive measures [5]. Patients with moderate to high cumulative BEWE scores, or with functional or esthetic compromise, may require adhesive restorations, onlays, or full-coverage restorations to protect remaining tooth structure and restore occlusal form. Regular recall allows longitudinal monitoring of erosion progression and timely escalation of care.
For a patient-friendly overview, see our companion guide, Acid Reflux and Your Teeth. Related reading: our review of xerostomia and salivary gland hypofunction and our preventative care program.
References
- Marsicano JA, de Moura-Grec PG, Bonato RC, Sales-Peres Mde C, Sales-Peres A, Sales-Peres SH. Gastroesophageal reflux, dental erosion, and halitosis in epidemiological surveys: a systematic review. Eur J Gastroenterol Hepatol. 2013;25(2):135-141.
- Li Y, Wang Z, Fang M. Association between gastro-oesophageal reflux disease and dental erosion in children: a systematic review and meta-analysis. J Dent. 2022.
- Ranjitkar S, Kaidonis JA, Smales RJ. Gastroesophageal reflux disease and tooth erosion. Int J Dent. 2012;2012:479850.
- Bartlett D, Ganss C, Lussi A. Basic Erosive Wear Examination (BEWE): a new scoring system for scientific and clinical needs. Clin Oral Investig. 2008;12(Suppl 1):65-68.
- Scribante A, Pardo A, Pascadopoli M, et al. Remineralizing treatments for dental erosion and sensitivity in patients suffering from gastroesophageal reflux disease (GERD): randomized clinical trial. J Clin Med. 2025;14(10):3525.
This article is provided for educational purposes only and does not constitute medical or dental advice. Clinical decisions should be individualized in consultation with a qualified dental professional and, for management of underlying reflux disease, a physician. If you have concerns about tooth wear or reflux symptoms, please contact Fridman Family Dental Care in Valencia, CA at (661) 254-3700.
