Hydrochloric acid: Helping patients understand the risks with taking acid-reducing medications

As a dental community, we often have a negative view of acids. While acids do have an impact on oral health, I’d like to broaden your perspective. Dental hygiene has given me the privilege of seeing firsthand what acid does to teeth. Erosive wear, caries, and sensitive teeth are just some of the issues caused by excessive acid in the oral environment. In hygiene school, I learned that the time exposure of acid on teeth was an important factor to consider when talking with patients about their dietary choices. However, I think there are more pieces to this puzzle.

Over the years of practicing clinical dental hygiene, I’ve noticed an increase in acid-reducing medications. In my practice, it’s not uncommon to have several patients a day who list some type of acid-reducing medication on their health history. Some have prescriptions while many others are self-medicating with over-the-counter (OTC) products. Many of my patients are unaware of the potential harm of acid-reducing drugs, especially if not taken as directed.

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OTC medications taken to reduce stomach acids are readily available for use and are generally safe, if used correctly. When asked, my patients are seldom aware that these medications are only to be used for a very short time and infrequently during the year.

Three levels of medications

Not all these medications work the same way. There are three levels of acid-reducing medications: antacids, histamine-2 blockers (H2), and proton pump inhibitors (PPIs).

Antacids primarily relieve heartburn or indigestion and work by neutralizing the acid with calcium carbonate and magnesium hydroxide. They can provide fast short-term relief, if taken as directed. For some, the high levels of calcium carbonate can cause constipation, nausea, mood changes, and heart rate changes. The brand names of this type are Mylanta, Rolaids, and Tums.¹

H2 blockers relieve and prevent heartburn by working to reduce the amount of acid produced by the stomach. They typically work within one to three hours and provide acid-suppression for several hours. They have shown to be effective in treating peptic ulcers and reflux in people who have heartburn a few times per month, but they are not intended for everyday use. These OTC medications have more side effects and can interfere with some prescription medications. Overuse can cause headaches, constipation, and nausea.¹

PPIs treat frequent heartburn occurring two or more days a week and are not intended for immediate relief of heartburn. Prescription PPIs are used to treat conditions such as gastroesophageal reflux disease (GERD), stomach and small intestine ulcers, and inflammation of the esophagus. PPIs reduce the amount of acid produced in the stomach and may interact with certain prescription drugs. OTC PPIs include: Prevacid, Nexium, Prilosec, and Zegerid.¹

Short-term use

While PPIs are helpful in managing severe heartburn, they are not recommended for more than the 14-day treatment. The overuse of PPIs can have harmful side effects such as infections, bone fractures, vitamin and mineral deficiencies, and possible increased risk of stomach cancer. Both PPIs and H2 antagonists may promote bacterial overgrowth in the small intestine and could exacerbate nonsteroidal anti-inflammatory drug-induced small intestinal injury. Acid-blocking drugs may increase the risk of peritonitis in some patients. Peritonitis is inflammation of the membrane lining the abdominal wall and covering the abdominal organs. It is usually infectious and often life-threatening.

“In contrast to prescription PPIs, OTC PPIs are marketed at low doses and are only intended for a 14-day course of treatment up to 3 times per year. FDA acknowledges that consumers, either on their own, or based on a healthcare professional’s recommendation, may take these products for periods of time that exceed the directions on the OTC label. Health-care professionals should be aware of the risk for fracture if they are recommending use of OTC PPIs at high doses or for longer periods of time than in the OTC PPI label.”²

As more of my patients began to list these medications on their health history, I became curious as to what the root causes might be. Medications other than antibiotics by and large do not cure diseases, but rather manage them by treating the symptoms. I began to ask: What is causing so much digestive disharmony? Too much acid? Not enough acid? Where does the balance lie?

Not a bad acid

Hydrochloric acid (HCl) is necessary to break down amino acids, which are the building blocks of hormones and many components of cells. The presence of food in the stomach stimulates the release of the hormone gastrin, which in turn signals the release of HCl. When HCl is present, the hormone pepsin is converted from an inactive form to an active form, which helps break down proteins.³

While I certainly don’t want my patients to have issues with their teeth and gums due to acid reflux or GERD, after learning about the importance of HCl, I felt it was my responsibility to coach my patients to explore the mystery of their symptoms.

As a health coach and clinical herbalist, I begin by asking patients about their lifestyle: What daily stresses are you dealing with? What does your diet consist of? The Standard American Diet (SAD) is populated in high carbohydrates, sugars, and salt, and as a busy population, convenience foods are often chosen over home-cooked meals. Often, these digestive symptoms can be better managed through lifestyle changes, such as dietary adjustments and stress management.

Clinical reflection

Samantha has been a patient of mine since she was a teenager. In her early 20s as a college student, she presented for her routine six-month dental visit. During this appointment, like most others, she presented with gingivitis. Despite efforts of brushing and flossing, she still had gingivitis. We had the same conversation we had so many times before with me encouraging her to do her very best at home. All the while, she presented with little calculus or plaque.

Fast-forward several years. Samantha returned once again for her routine appointment, but this time I had a better understanding of the body and the delicate balance it strives for. I began by asking Samantha some questions about her diet and lifestyle. As we discussed possible causes and solutions, by the end of the appointment, she decided to try an elimination diet and see what happens.

Six months later, Samantha returned with a big smile. She told me she couldn’t wait to come back to see me and report what she had discovered. Turns out Samantha has a sensitivity to gluten. Since avoiding gluten in her diet, her gums have gotten better. The surprising thing for her was the change in her digestive system. This is what she told me: “I’ve had bellyaches after eating my whole life. I thought everyone did because I don’t remember a time when I didn’t. That is, until I stopped eating gluten. Now my gums are better, and my stomachache is gone.”

A 2008 controlled clinical trial looked at the effects of a gluten-free diet on preventing recurrence of GERD. The conclusion suggested that a gluten-free diet could be a useful approach in reducing GERD symptoms and in preventing recurrence.4 While every patient’s root cause will be individualized, this perspective gives rise to possibilities.

On the other hand

On the other hand, too little HCl is equally as destructive as too much. HCl plays an important role in absorption of minerals such as calcium, magnesium, and zinc.⁵ HCl kills bacteria. Without sufficient HCl, bacterial overgrowth can occur in the intestines, increasing phlegm and slowing down the digestive process. When there is insufficient HCl, undigested food can back up into the stomach and create heartburn. This is because there is not enough HCl present to break it down and move it through the system.

Achlorhydria is a condition in which the stomach does not produce HCl. Multiple disorders can cause this problem such as pernicious anemia, certain medications, Helicobacter pylori infection, gastric bypass, and hypothyroidism.⁶

Depending on the primary cause, the symptoms of achlorhydria can vary, but generally present in:

• Weight loss
• Heartburn
• Nausea
• Bloating
• Diarrhea
• Abdominal pain
• Acid regurgitation
• Early satiety
• Vomiting
• Postprandial fullness
• Constipation
• Dysphagia
• Glossitis

Many of these symptoms of too little HCl are similar to those with excess HCl. Chewing, of course, stimulates saliva flow and digestive motility that can improve gastroparesis. Studies suggest that chewing alone may reduce reflux, improving the clearance of refluxate (material that has leaked into the esophagus) from the esophagus that can last up to three hours.

Chewing xylitol gum has many benefits to dental health along with reducing childhood ear infections; notably, it has been shown to increase gastrointestinal motility recovery following major surgeries.⁵

Making the difference

Medical tests can be performed to confirm the diagnosis and the primary cause of acid reflux. Oftentimes, “band-aid” remedies are sought but fail to treat the root of the problem. As you can see, the symptoms of both too much HCl and too little HCl are similar. In my research, I was most surprised to find hypothyroid disease is listed in the “too little” HCl production. I’m certain that at least a third of my patients have thyroid disease. Supplements containing HCl can be used prior to eating for those with too little acid.

Armed with this new information, I can now help my patients understand the acid-reducing medications they are taking, the role they play in their digestive system, and how to take the next step in finding a solution. Join me in helping our patients understand the risks of prolonged use of acid-reducing medications and encourage them to uncover the real reason behind the problems. 

Editor's note: This article appeared in the November 2022 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.

References

1. Over-the-counter (OTC) heartburn treatment. U.S. Food and Drug Administration. March 12, 2021. https://www.fda.gov/drugs/information-consumers-and-patients-drugs/over-counter-otc-heartburn-treatment
2. FDA drug safety communication: possible increased risk of fractures of the hip, wrist, and spine with the use of proton pump inhibitors. U.S. Food and Drug Administration. August 3, 2017. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/fda-drug-safety-communication-possible-increased-risk-fractures-hip-wrist-and-spine-use-proton-pump
3. Maier K. Energetic Herbalism. Chelsea Green Publishing; 2021.
4. Usai P, Manca R, Cuomo R, Lai MA, Russo L, Boi MF. Effect of gluten-free diet on preventing recurrence of gastroesophageal reflux disease-related symptoms in adult celiac patients with nonerosive reflux disease. J Gastroenterol Hepatol. 2008;23(9):1368-1372. doi:10.111/j.1440-1746.2008.05507
5. Stansbury J. Herbal Formularies for Health Professionals. Chelsea Green Publishing; 2018:48.
6. Fatima R, Muhammad A. Achlorhydria. In: StatPearls. May 1, 2022. Updated June 5, 2022. https://www.ncbi.nlm.nih.gov/books/NBK507793/#:~:text=Achlorhydria%20is%20a%20condition%20in,ingested%20with%20food%20or%20water