Gastric Bypass Surgery Can Lead To Dental Problems

For many, gastric bypass surgery is the only realistic means of overcoming obesity and the myriad associated health issues. In my practice, more and more patients are opting for gastric bypass surgery, often with dramatic results. One 18 month follow-up study found a 57% recovery from diabetes, an 84 % cure from cholesterol problems, and a 47% cure from high blood pressure.(1) These are all really good reasons to support the recommendations for surgery. Since the results from having gastric bypass surgery can be obtained from diet and lifestyle modifications, candidates must demonstrate that they have tried more conventional methods first, have a BMI of 40 or above, or have a BMI of 35 with other health related issues like diabetes.

 Unfortunately, I often see uncontrolled tooth decay and tooth loss post-operatively. The reasons have not been widely investigated. There are a few logical explanations as to why this is happening.

Before I get into the reasons, let me give some background on the digestive process. Digesting food is a sequential and finely tuned mechanism. The stomach stores your meal, mixes it with acid that breaks it down. When the food is ready, the stomach releases the meal (now called chyme) into the first part of the intestine called the duodenum. It must have an acidity strong enough to signal your gall bladder and pancreas to secrete enzymes and bile into the chyme to further break down the food particles into small molecules that can be absorbed. Protease helps breakdown protein into amino acids, Lipase helps to breakdown fat, bile dissolves the fat so it can mix with your blood, and carbohydrase helps breakdown starches into simple sugars. The small intestine is responsible for absorbing the fats, amino acids, and sugars along with the minerals and vitamins your meal contains.  It is 23 feet long because it takes quite a bit of surface area to ensure that you absorb all the nutrients your body needs to function and repair itself.

Now let me briefly describe what gastric bypass surgery is. The gold standard is known as Roux-en-Y surgery and involves separating the top of the stomach and connecting it to an area of the small intestines farther down, BYPASSING most of the stomach and some of the small intestines. The remaining unused part of the stomach is reattached to the small intestines to allow the digestive juices to continue to help digestion.

     The logic to the surgery is as follows: The much smaller portion of the stomach that remains will only hold a fraction of the food that the entire stomach previously did. The stomach stretches very early so your brain thinks you are full, and you stop eating. The unused portion of your stomach is reattached lower down on your intestines to allow it to continue to secrete gastric juices that aid in digesting your food. Unfortunately, this delays the mixing of gall bladder and pancreatic secretions with food in the section of the small intestines just below the old stomach, which can contribute to poor digestion and absorption of several nutrients.

I want to back up a bit here. It has been noted that obese individuals are malnourished already and suffer numerous nutritional deficiencies. This is likely due to higher intake of calorie dense, but nutrient sparse food. (2, 3) My obese patients have higher rates of tooth decay due to these nutrient deficiencies. Common nutritional deficiencies AFTER gastric bypass surgery are: iron, B12, folate, copper, calcium, and vitamin D. (4) The most common symptoms are anemia (up to 74%) and neurological dysfunction (5–9%) (5, 6) For this reason, patients are placed on supplements and monitored for deficiencies after surgery. Despite this, nutritional deficiencies are generally universal postoperatively. (7)

Now, let’s talk about post surgical cavities and loss of tooth structure. As I stated previously, cavities are largely due to nutritional deficiencies and excess processed carbohydrate intake. Read more about this in my previous post. Gastric bypass can increase loss of tooth structure and decay by exacerbating nutritional deficiencies. Our primary defense against decay is our saliva. Salivary production relies heavily on proper absorption of nutrients. Patients who have had bypass surgery have lower salivary flow and more acidic mouths, which can lead to mineral loss in teeth and subsequent pain and tooth decay. (8, 9)

Gastric reflux and vomiting are very common postsurgical manifestations and increase the risk for loss of tooth structure and the associated sensitivity, particularly in the presence of other risk factors such as consumption of sweet-tasting foods and acidic beverages.(10) Almost 80% of patients experience vomiting just after surgery. 37% of patients reported major hypersensitivity after surgery and 44% reported vomiting associated with high sensitivity. Several studies showed that of the 32% that suffered from indigestion after surgery, 59% reported hypersensitivity and 80% of the patients have visited the dentist due to hypersensitivity. Some clinical case reports also showed the relation between bariatric surgery and increase of tooth decay.(11,12,13) These statistics are quite compelling and a bit concerning.

There is a lack of quality studies and more research is needed to shed more light on the connection. I am not suggesting you delay your gastric bypass surgery as the benefits may save your life. I just want you to know some of the associated dental risk factors associated with the procedure.