Can gastroesophageal reflux disease (GERD) cause brown tooth staining?

Can Acid Reflux Cause Brown Tooth Staining?

Yes, gastroesophageal reflux disease (GERD) can cause tooth discoloration and erosion, though the primary dental manifestation is enamel erosion rather than brown staining per se—the brown appearance typically results from secondary changes after the protective enamel layer has been chemically dissolved by gastric acid exposure. 1, 2

Mechanism of GERD-Related Dental Damage

The pathophysiology involves direct chemical dissolution of tooth enamel without bacterial involvement:

• Gastric acid regurgitation brings stomach contents (pH typically 1-2) into contact with tooth surfaces, particularly affecting the palatal (tongue-side) surfaces of upper front teeth and occlusal (biting) surfaces of back teeth 3, 4
• Enamel demineralization occurs as the strong gastric acids (including hydrochloric acid and pepsin) chemically dissolve the hard enamel surface, leading to progressive tissue loss 1, 5
• Secondary discoloration develops as the underlying dentin becomes exposed after enamel loss—dentin is naturally more yellow-brown than enamel and more susceptible to staining from dietary sources 3

Clinical Presentation and Recognition

GERD-related dental erosion has distinctive patterns that help differentiate it from other causes:

• Location specificity: Erosion predominantly affects palatal surfaces of maxillary anterior teeth and occlusal surfaces of posterior teeth, sparing areas typically affected by dietary acids 4, 5
• Silent presentation: Up to 75% of patients with GERD-related dental erosion may have no gastrointestinal symptoms like heartburn, making dental findings the first clinical sign 6, 4
• Progressive nature: Without treatment of the underlying GERD, enamel loss continues at approximately 0.8% of total thickness per 3-week period in untreated patients 2

Diagnostic Approach

When brown tooth staining or erosion is identified:

• Examine tooth surfaces for characteristic patterns: smooth, concave erosions on palatal surfaces of upper front teeth, cupping of posterior tooth chewing surfaces, and loss of normal enamel anatomy 3, 4
• Distinguish from other causes: Rule out bulimia (typically affects lingual surfaces of lower teeth more), dietary acid exposure (affects labial/facial surfaces), and mechanical wear patterns 4
• Refer for GERD evaluation when dental erosion pattern suggests acid reflux, even without gastrointestinal symptoms—24-hour esophageal pH monitoring can confirm abnormal acid exposure (>4% of time with pH<4) 2, 4

Management Strategy

Treatment requires addressing both the underlying GERD and the dental damage:

• Medical management first: Acid suppression with proton pump inhibitors (esomeprazole 20 mg twice daily demonstrated 50% reduction in enamel loss progression over 3 weeks compared to placebo) must precede definitive dental restoration 2
• Delay restorative work until GERD is controlled—attempting dental rehabilitation while active acid exposure continues leads to restoration failure 3, 5
• Definitive restoration: After medical control is achieved, use direct resin composites to restore lost tooth structure and protect remaining enamel from further acid exposure 3, 5

Critical Clinical Pitfalls

• Missing the diagnosis: Dentists are often the first healthcare providers to identify GERD through dental erosion patterns, particularly in asymptomatic patients—failure to recognize this connection delays both medical and dental treatment 4
• Premature restoration: Placing restorations before achieving medical control of acid reflux results in continued enamel loss around restorations and restoration failure 3, 5
• Assuming symptoms are required: The absence of heartburn or regurgitation does not exclude GERD as the cause of dental erosion—maintain high suspicion based on erosion pattern alone 6, 4