Acid Reflux (GERD, LPR) Teeth Problems – Enamel Erosion

Disclaimer: please note that this article is mostly focused on GERD/LPR related dental problems and provides only basic advice regarding treating acid reflux itself. Be aware that GERD/LPR may be a serious condition leading to life-threatening diseases like Barett's Esophagus or even esophageal cancer. It should be diagnosed and treated by a physician, not self-diagnosis on the Internet.

There are two main types of acid reflux disease: (1) typical acid reflux called GERD (Gastroesophageal reflux disease) or GORD (Gastro-oesophageal reflux disease) and (2) LPR (Laryngopharyngeal Reflux). The first one is easy to diagnose as it causes chest pain often referred to as heartburn. It can appear right after eating spicy food or more frequently if the disease is more advanced. The latter kind, LPR is often called Silent reflux, because you may be suffering from it without even knowing that you have reflux disease. Apparently, your dentist may be the first person to inform you about it!
This is because this form of reflux often manifests itself via enamel erosion and increased susceptibility for dental caries (cavities). This is because this reflux type often works as gas reflux and it lowers pH level in the oral cavity. During the day, thanks to saliva and its buffering capacity pH level should be within a healthy range (close to neutral pH 7.0), but when you sleep, the situation becomes more difficult as saliva production decreases (even in healthy individuals) and so your oral pH levels. Also, your reflux in the supine position may be more serious and if it was not enough also mouth breathing can make things even worse. Prolonged low pH levels not only erode your enamel but also negatively affect your oral microbiome by promoting bad bacteria that are more resistant to acidic environment than the good ones.

First steps – correct diagnosis

If you suspect that you have reflux disease and also suffer from dental problems you should consider proper testing. The gold standard test for GERD is endoscopy manometry and pH-impedance testing and the gold standard test for LPR type or reflux is Restech (oral cavity 24-hour pH monitoring). If reflux is causing your teeth problems its mechanism is fairly simple – acid produced in your stomach (pH level of around 2.0) gets up your esophagus due to ineffective LES (Lower Esophageal Sphincter) either in gas (LPR) or liquid form (GERD). Your enamel can handle pH levels not lower than the critical pH of pH 5.5, and your reflux episodes (especially the night ones) can decrease it even below pH 4.0 for prolonged periods of time, which may be very harmful.
pH levels can be measured at home with handy electronic equipment – we recommend ordering a cheap electronic pH meter (made in China) off AliExpress listings. These cost less than $10 shipped directly from China and can very accurately display your saliva pH level in real-time. By simply spitting saliva on the electrode you will get an instant, precise reading of your saliva pH level. After purchasing a pH meter you will be able to learn how acidic is your mouth during the night – if it falls below 6.2 pH (or even worse, below 5.5 pH) it is recommended that you use medication or other interventions to increase these to safe levels values. The healthy saliva pH level is around 7.0 (daytime) and not lower than 6.2 (nighttime). Please note that saliva pH can drop even in healthy individuals, but in these people, it always stays within the safe range.

General interventions and handling of LPR acid reflux

Below we have prepared a short guide on how to handle LPR reflux type-related teeth problems. First comes the list of handling reflux-related issues:

1. PPI (Proton Pump Inhibitors) medication ⁽¹⁾
   While these are really effective for GERD, medical papers often conclude they are no better than placebo in treating LPR, therefore are not recommended. Please be aware that PPIs are not intended for long-term use and may have some significant side effects. LPR is assessed with RYAN score and after 12 weeks on PPIs, only 40% of patients were full responders with pH and symptoms normalization.
2. Low acid diet
   Ideal LPR recommended diet consists of only pH > 7 food and only of pH > 8 drinks (that is mostly alkaline water). Recommended books that cover this topic are Dropping Acid book and The Acid Watcher Diet.
3. Eating more frequent, smaller meals
   This helps you reduce regurgitation and reflux episodes, but please keep in mind that more frequent eating causes more hassle when it comes to oral hygiene, as you should have your teeth and gums cleaned after each meal, but not instantly after finishing eating (that’s because enamel softens after acid exposure and can be damaged by brushing).
4. Weight loss (if applicable) and not wearing tight clothes ⁽²⁾
   By losing weight your LES will have less pressure on it making it function better. It is also a good idea to avoid wearing tight belts, especially after eating as these can also create extra pressure on the abdomen area.
5. Drinking alkaline water (that is pH 8.8 or higher)
   Alkaline water above that pH level will neutralize pepsin which is the main culprit of the LPR reflux. You can mix it with baking soda and additionally gargle for a few seconds.
6. Foam barrier medication ⁽³⁾
   Gaviscon Advance (liquid or tablets – UK/European version only, US Gaviscon is something different) or Life Extension Esophageal Guardian (tablets only). These work by forming a kind of an alginate raft on top of your stomach – this foam layer protects your stomach contents from coming back up and last couple of hours. We tested both forms of Gaviscon and the liquid appears to be more convenient but sadly it contains preservatives that are not present in the form of tablets.
7. Digestive upplements ⁽⁴⁾
   D-Limonene, DLG (deglycyrrhizinated licorice), and Digestive enzymes – all of these improve your digestion, which helps to empty your stomach faster and gives fewer chances to reflux.
8. Wedge pillow / sleeping on an incline ⁽⁵⁾⁽⁶⁾
   Say goodbye to sleeping flat – the simplest intervention is to put blocks underneath the legs of your bed so that your mouth is always higher than your stomach (the larger the difference, the better). You can also but specialistic sleeping pillows like MedCline Acid Reflux Relief Bed Wedge and Body Pillow System. They will force you to sleep on your left side which is the best position. Sleeping on your back or stomach is also okay given that your bed is angled. Try to avoid sleeping on your right by all means.
9. IQoro device to treat hiatal hernia and increase LES pressure ⁽⁷⁾
   We have not tested that device yet, but you can read the linked PubMed publication. The main problem with it is that it is really expensive for a small piece of plastic.
10. Inspiratory Muscle Training to increase LES pressure ⁽⁸⁾
    We are currently testing this kind of device, and also small group studies linked below show it may improve LES function. Here’s an example of such device on Amazon.
11. Rezaband or Refluxband medical device for LES
    We have tested this device and will prepare a full review but it’s not a miracle cure, it may be helpful during the night but it has many drawbacks like choking discomfort or dislocation during sleep.
12. Chewing sugar free gum after meals ⁽⁹⁾
    This simple intervention helps you produce more saliva which helps remineralize your teeth as well as clear your throat and esophagus. It’s important to remember not to chew your gum for too long as this may overgrow your jaw muscles and cause other problems like bruxism. We recommend gum without preservatives and with added xylitol for extra protection against dental caries like Spry (our favourite, mostly because it’s easiest to get where we live), Pur or Epic.
13. Avoiding alcohol and smoking
    They both make your LES (Lower Esophageal Sphincter) weaker which usually is the main reason why you suffer from reflux disease.
14. Melatonin before going to bed⁽¹⁰⁾
    There are studies as well as meta-analyses concluding that melatonin reduces reflux incidents. Please note that melatonin is suitable only when you intend to go to sleep soon.
15. Antireflux surgeries ^{(11)(12)(13)(14)}
    When everything else fails there are plenty of surgical options to be discussed including Nissen fundoplication, Linx, Stretta, TIF, Endostim, and more. These interventions may be the best choice if your reflux is persistent and decreases your quality of life. We won’t be discussing these as each surgical option requires certain conditions to be met so you have to discuss these with your health professional.

Dental interventions to protect your teeth from acid reflux (LPR and GERD)

Now let’s present dental interventions you can make to protect your teeth from acid and pepsin (in case you have LPR type of reflux).

1. Mouth taping during the night
   Mouth taping is recommended if you breathe through your mouth while sleeping. If you ever wake up and your mouth is dry or saliva in your mouth is not as normal you should consider taping. Please read a separate article on mouth-taping to learn about all the benefits it has! You can also try an anti-snoring chin strap as an alternative.
2. Using enamel protecting toothpaste and mouthwash (low RDA score with acid protection)
   These are Sensodyne Pronamel and Elmex Dental Enamel Protection Professional. You should avoid whitening and high-abrasive kinds of toothpaste, especially charcoal toothpaste. When brushing with protective toothpaste before going to sleep do not rinse your mouth with water. Just spit out excess toothpaste and leave the rest on your teeth. How does it work? In the case of Elmex Professional, their ChitoActive technology contains chitosan (which is a biopolymer of natural origin), tin chloride, and amine fluoride and supports the formation of a tin-rich protective layer on the surface of the teeth.
3. Using fluoride to remineralize teeth
   This routine can be performed on a weekly basis to strengthen and remineralize your enamel. There are fluoride concentrates available off the counter, but be really careful when using them as fluoride in higher concentrations is more toxic than ingested.
4. Using Hydroxyapatite (HAp) paste to remineralize teeth
   This is a safer fluoride alternative, which you can use instead of or interchangeably with fluoride. Hydroxyapatite is usually named nano-hydroxyapatite on the ingredients list and is available both as toothpaste or in higher-concentration gels. The main advantage is that it’s not harmful to your body which means you can leave high-concentration gel on your teeth as a remineralizing agent in your Invisalign or protective tray.
5. Using pH neutralizing gels with Invisalign or mouth guards
   If you suffer low pH while you sleep you can use Invisalign or mouth guards as trays for pH neutralizing gels – this way even when your oral cavity pH drops below safe values your teeth will be still soaked in pH-neutralizing solution keeping them safe from acid.
6. Measuring pH levels of your saliva during the day and right after waking up (mid-sleep wake-up test is also a good idea)
7. H2 antagonists or Gaviscon Advance before going to bed (recommended in case of high pH morning readings)
   Gaviscon Advance is a physical barrier – protective lining on top of your stomach content and H2 antagonists are lowering your acid production for about 12 hours. H2 antagonists are recommended 1-2 hours before bedtime and Gaviscon Advance right before bed – do not drink anything after.
8. Not eating at least 4 hours before going to bed
   This advice is fairly simple – you want to have an empty stomach when going to bet as your digestion slows down and a full stomach may cause pressure on your LES valve causing it to reflux.
9. Avoiding brushing first thing in the morning and after acidic meals or drinks
   You should learn if the food you eat is acidic or close to neutral. In the first case, you should wait about half an hour before brushing your teeth, and in the second case, you can brush almost instantly after finishing eating. The same applies to morning brushing – if your pH meter shows a healthy saliva pH value you can brush right away, however, if you tend to have too low pH levels during the night it’s recommended to brush once you rinse your mouth with alkaline water and give it some time to normalize.
10. Wearing a night guard
    This is a must-have if you have teeth grinding (bruxism) problems, as your teeth soaked in acid will degrade a lot faster than in healthy pH levels. In case you do not have this kind of issue, be aware that saliva under your night guard will be less frequently replaced, which can be a problem if you have large pH drops during the night, so using it without bruxism may be counter-productive.

LPR and GERD and their link to teeth problems is a topic that will be extensively covered in our book, but since it’s an important and widespread health issue we have decided to publish an article with our findings before the book is ready.

If you have any questions regarding these recommendations do not hesitate and ask them in the comments section below. We’ll do our best to help! Below we publish a full list of references – we will link them to the claims mentioned above soon.

Full references list:

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2503658
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3853378f
3. https://www.ncbi.nlm.nih.gov/pubmed/26909885
4. https://www.ncbi.nlm.nih.gov/pubmed/18072821
5. https://www.ncbi.nlm.nih.gov/pubmed/28688630
6. https://www.ncbi.nlm.nih.gov/pubmed/27629558
7. https://www.ncbi.nlm.nih.gov/pubmed/25963055
8. https://www.ncbi.nlm.nih.gov/pubmed/23026445
9. https://www.ncbi.nlm.nih.gov/pubmed/16246942
10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6358381
11. https://www.ncbi.nlm.nih.gov/pubmed/24562599
12. https://www.ncbi.nlm.nih.gov/pubmed/28233093
13. https://www.ncbi.nlm.nih.gov/pubmed/22098922
14. https://www.ncbi.nlm.nih.gov/pubmed/28928332

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This article is complete and was published on June 29, 2020, and last updated on June 7, 2023.