Dental manifestations in bariatric patients – review of literature

ABSTRACT The rate of bariatric surgery has significantly risen in the past decade as an increasing prevalence of extreme obesity can be observed. Although bariatric surgery is an effective therapeutic modality for extreme obesity, it is associated with risk factors affecting also oral health. Based on an overview of the current literature, this paper presents a summary of dental manifestations in bariatric patients. Bariatric surgeries are associated with an increased risk for gastro-esophageal reflux which in turn might account for the higher amount of carious and erosive lesions observed in bariatric patients. As a result, also dentin hypersensitivity might be observed more frequently. The current data indicate that recommended postsurgical meal patterns and gastric reflux might increase the risk for dental lesions, particularly in the presence of other risk factors, such as consumption of sweet-tasting foods and acidic beverages. Further research is needed to evaluate the correlation of bariatric surgery and the development of dental diseases.


INTRODUCTION
Modern methods to reduce the weight of adipose patients, including bariatric surgery techniques, have been developed for the treatment of obesity especially in its morbid form 22,30 . Bariatric surgery is considered as effective and safe treatment for all ages, increasing in prevalence over the years 22,30 . Since the implementation, the surgical techniques have undergone great changes along the time, for both the improvements of the tools and the post-operative sequels 1 .
Nowadays, there are 3 main surgery techniques reported 22 . One technique is the Gastric Band, in which a silicone ring is placed around the stomach, thus creating two compartments: a small one above (15-20 mL) that will store small quantities of food, thus generating a sense of satiety, and the other part is larger and placed below, which will take part of normal digestion 8 .

Another option is Gastric bypass Roux-in-Y
technique, in which a small pouch is created (15 to 30 mL) stapling the stomach itself, restricting the amount of food that can be consumed. A part of the small intestine is diverted, delaying the mixing of food with gastric juice 15 . Finally, Misuse Biliopancreatic is performed in a way that ¾ of the stomach are removed and the intestine is shortened, reducing the time of contact of food with the intestine, considerably reducing the absorption of the nutrients 22 .
There are many factors that might influence the results. In this sense, it is worth mentioning that the elderly patients are more likely to develop post-surgical complications, attributed to lower functional reserve of this age group, in addition to the presence of other metabolic diseases such as diabetes, which led significant sequel in these patients 4,9 . Regarding this issue, post-bariatric surgery manifestations include gastro-esophageal, respiratory, cardiovascular, endocrine and psychological changes 24  Based on above considerations, the aim of this paper was to present a summary of dental manifestations in bariatric patients.

Dental Erosion
One of the lesions related to the demineralization is the dental erosion, which is defined as chemical

Dental caries
Dental caries is a multifactorial disease, whose aetiology is related to the presence of a dental plaque composed by cariogenic bacteria, which can metabolize sugars such as sucrose. As a result of this metabolism, organic acids are produced such as lactic acid, which in turn can induce the demineralization of dental tissues 16,29 . With time, the biofilm becomes saturated regarding minerals that are released from the dental structure, favouring the precipitation and the formation of an initial subsurface carious lesion 6 Two processes are essential for its development: (1) dentin must be exposed through genetic

Clinical impact of the knowledge
Based on above considerations, medical and dentist teams need to consider potential dental problems after bariatric surgery, and to supply their patients with the appropriate information and instructions regarding oral hygiene maintenance, healthy dietary patterns and regular dental health monitoring by a dentist or dental hygienist.

CONCLUSION
The present review suggests that postsurgical meal patterns and gastric reflux might increase the risk for dental lesions, particularly in the presence of other risk factors such as consumption of sweet-tasting foods and acidic beverages.
However, due to a lack of data, more research is needed to evaluate this relationship.