Association Between Gastroesophageal Reflux Disease (GERD) Symptoms, Dental Health, and Cariogenic Microorganisms in the Oral Cavities of Children

Association Between Gastroesophageal Reflux Disease (GERD) Symptoms, Dental Health, and Cariogenic Microorganisms in the Oral Cavities of Children | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Association Between Gastroesophageal Reflux Disease (GERD) Symptoms, Dental Health, and Cariogenic Microorganisms in the Oral Cavities of Children Amirhossein Bagherzadeh, Mohammadreza Esmaeili Dooki, Mehrdad Halaji, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8743252/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 14 You are reading this latest preprint version Abstract Background: The acidic nature of gastric refluxate, combined with the enhanced proliferation of Streptococcus mutans and Streptococcus sobrinus in acidic environments, underscores the potential impact of gastroesophageal reflux disease (GERD) on oral health. This study aimed to explore the relationship between dental health status and microbial load in the oral cavity of children diagnosed with GERD symptoms, in comparison to compared with healthy controls. Methods: This case-control study involved 32 children with GERD and 37 healthy children, aged 5 to 11 years. GERD symptoms were assessed using the GERD Assessment of Symptoms in Pediatrics Questionnaire (GASP-Q). Dental health was evaluated using the decayed, missing, and filled teeth (dmft/DMFT) index. Microbial load was measured by sampling the tongue and cheeks with sterile cotton swabs, followed by the quantification of S. mutans and S. sobrinus . Statistical analyses were performed using Chi-square tests, independent T-tests, Pearson correlation coefficients, and logistic regression with SPSS software, at a significance level of 0.05. Results: The mean age of the children was 8.22 ± 1.92 years. No significant differences were observed between the case and control groups in terms of mean age (P = 0.379) or sex distribution (P = 0.126). There was no significant difference in the dmft/DMFT index scores between the two groups (P = 0.410). However, the mean bacterial count was significantly higher in the GERD group compared to the control group (P < 0.001). A significant linear relationship was found between GERD symptoms and bacterial load in children aged 8 years or younger (Beta = 0.645, P < 0.001). Conclusion: While GERD was associated with an increased levels of cariogenic bacteria in the oral cavity, no significant effect on dental caries rates was observed. Gastroesophageal Reflux Dental Caries Oral Hygiene Streptococcus mutans Streptococcus sobrinus Figures Figure 1 Figure 2 Figure 3 Introduction General health is closely linked to oral and dental health. As part of the digestive system, the oral cavity can reflect underlying gastrointestinal disorders such as celiac disease, gastroesophageal reflux disease (GERD), and inflammatory bowel diseases [ 1 ]. Gastroesophageal reflux (GER) is a normal physiological process that occurs several times daily in healthy individuals, including both children and adults. It involves the involuntary passage of stomach contents into the esophagus [ 2 ]. However, GERD refers to the pathological symptoms and complications arising from GER, typically due to the impaired function of the lower esophageal sphincter, which fails to prevent the backflow of stomach contents into the esophagus [ 1 ]. Streptococcus mutans and Streptococcus sobrinus are widely recognized as the primary etiological agents of dental caries in humans. Extensive research conducted over several decades has established a strong association between the salivary levels of these bacteria and the onset of dental caries [ 3 , 4 ]. Alterations in the microbial composition of the tongue, coupled with an overgrowth of S. mutans in dental plaque, indicate the presence of an oral environment that may favor the development of dental caries. While a direct causal relationship between changes in the tongue's microbial flora and the onset of caries has yet to be definitively established, the strong correlation between the proportion of commensal bacteria in the tongue microbiome and salivary levels of S. mutans suggests a potential link [ 5 ]. To date, only a limited number of studies have examied the association between GERD and dental caries, and their findings have been inconsistent. For example, Sîmpălean et al. found no significant effect of GERD on dental caries incidence [ 6 ]. In contrast, Corrêa et al. reported a negative relationship between GERD and dental caries [ 7 ]. Gaining a clearer understanding of this relationship could be crucial for enhancing oral hygiene practices and preventing the onset of dental caries [ 8 ]. Given the acidic nature of gastric reflux contents and the enhanced growth of S. mutans and S. sobrinus in acidic environments, the present study aimed to investigate the relationship between the dmft/DMFT index and oral levels of S. mutans and S. sobrinus in children with gastroesophageal reflux disease (GERD), compared to healthy controls. Materials and Methods This case-control study included 69 children aged 5 to 11 years, 32 with GERD and 37 healthy controls who visited a specialized pediatric gastroenterology and hepatology clinic. The sample size was calculated based on similar studies [9], using a 95% confidence level (α = 0.05) and 80% statistical power (β = 0.2), with the following formula: where: S1=2.5, S2=1.3, and d=1.5 After obtaining written informed consent from the parents, the children were evaluated. The diagnosis of GERD was determined using the Gastroesophageal Reflux Disease Assessment in Pediatrics (GASP-Q) questionnaire. Children with a total symptom score (CSS) of ≥16 were evaluated as having GERD [10]. Dental status was assessed using the dmft/DMFT index, which measures decayed, missing, and filled teeth. Evaluations were conducted using a dental mirror and probe under natural room light. Oral samples were collected with sterile cotton swabs from the tongue and buccal mucosa. Participants were instructed to refrain from eating, drinking, brushing their teeth, or using mouthwash for at least 30 minutes before sampling. Swabs were taken from the anterior two-thirds of the dorsal surface of the tongue and the buccal grooves of both the upper and lower jaws, with each side swabbed for 10 seconds. Serial dilutions of the samples were prepared, and S. mutans and S. sobrinus were cultured using the spread plate method on Mitis Salivarius Bacitracin Agar and Blood Agar containing sheep blood. The cultures were incubated at 37°C for 24 hours in a candle jar. Suspected colonies were identified macroscopically and microscopically, and colony counts were expressed in CFU/mL [11-13]. Data Analysis Statistical analysis was performed using SPSS software (version 26.0; IBM Corp., Armonk, NY, USA). The normality of the data was assessed using the Kolmogorov-Smirnov test. Independent t-tests and chi-square tests were used to compare groups. Pearson correlation coefficients were calculated to assess relationships among variables, and logistic regression was used to evaluate the association between variables and outcomes. A significance level of P < 0.05 was considered statistically significant. Results Table 1 summarizes the characteristics of the study participants in the GERD and control groups. No statistically significant differences were observed in age or sex distribution between the case and control groups (P = 0.379 and P = 0.126, respectively). Table 1 Comparison of Variables Studied Between the Case and Control Groups Variable Children with GERD (n = 32) Healthy Children (n = 37) P-value Total (n = 69) Age (years) 8.44 ± 1.97 8.03 ± 1.88 0.379* 8.22 ± 1.92 Gender Male 14 (43.6%) 23 (62.2%) 0.126** 37 (53.6%) Female 18 (56.3%) 14 (37.8%) 32 (46.4%) GERD Score 128.38 ± 61.14 0 < 0.001* 59.54 ± 76.57 dmft 4.78 ± 5.02 5.16 ± 4.17 0.732* 4.99 ± 4.55 DMFT 1.41 ± 1.83 0.7 ± 1.51 0.089* 1.03 ± 1.69 dmft + DMFT 6.16 ± 5.01 5.86 ± 4.14 0.41* 6 ± 4.53 Bacterial Count (CFU/mL) 4.1 × 10⁶ ± 5.6 × 10⁶ 1.5 × 10⁵ ± 3.2 × 10⁵ < 0.001* 2.0 × 10⁶ ± 4.3 × 10⁶ * Independent samples t-test **Chi-square test The mean GERD score in children with GERD was 128.38 ± 61.14. No significant differences were observed between the groups for the mean dmft, DMFT, and combined dmft + DMFT scores (P = 0.732, P = 0.089, and P = 0.41, respectively). However, bacterial counts of S. mutans and S. sobrinus were significantly higher in children with GERD than in healthy children (P < 0.001). Distribution of dmft and DMFT Scores Based on Bacterial Growth The distribution of dmft scores according to bacterial growth in culture is shown for each study group in Fig. 1 . As shown, bacterial growth was lower in healthy children compared to GERD. Additionally, in children with GERD, higher bacterial growth was associated with higher dmft scores. As shown in Fig. 2 , bacterial growth was significantly lower in healthy children than children with GERD. This suggests a potential correlation between increased bacterial growth and higher DMFT scores in children with GERD. Figure 3 shows the combined dmft + DMFT scores based on bacterial growth in culture. As shown in the figure, bacterial growth was significantly lower in healthy children compared to children with GERD. In the GERD group, higher bacterial growth was associated with higher combined dmft + DMFT scores, suggesting a relationship between increased bacterial growth and the severity of dental caries. Association Between GERD and dmft, DMFT, and dmft + DMFT Indices in Children with GERD The relationship between GERD scores and the dmft, DMFT, and combined dmft + DMFT indices was analyzed using linear regression and scatter plots. No statistically significant correlation was found between GERD scores and dmft (Beta = 0.002, P = 0.986), DMFT (Beta = 0.179, P = 0.140), or the combined dmft + DMFT (Beta = 0.065, P = 0.597). These results remained statistically insignificant even after adjusting for the children's ages (P > 0.05). Association Between GERD and Bacterial Counts in Children with GERD A significant positive association was found between GERD scores and bacterial counts in culture, as indicated by linear regression analysis (Beta = 0.457, P < 0.001). This association remained statistically significant even after adjusting for age (Beta = 0.482, P < 0.001). Association Between GERD and Factors of dmft, DMFT, dmft + DMFT indices, and Bacterial Counts by Age Groups in Children with GERD Children were categorized into two age groups: 8 years and younger, and older than 8 years. The relationships between GERD scores and dmft, DMFT, dmft + DMFT indices, and bacterial counts were analyzed separately for these age groups. The results are presented in Table 2 . Table 2 The Relationships Between GERD Scores and dmft, DMFT, dmft + DMFT Indices, and Bacterial Counts by Age Groups Factor Age ≤ 8 Years Age > 8 Years Beta P-value Beta P-value dmft 0.219 0.158 -0.152 0.459 DMFT 0.066 0.675 0.151 0.749 dmft + DMFT 0.224 0.149 -0.06 0.769 Bacterial Count (CFU/mL) 0.645 < 0.001 0.124 0.572 A significant positive association was found between GERD scores and bacterial counts only in the 8 years and younger (Beta = 0.645, P 0.05). Discussion This case-control study explored the association between dmft/DMFT indices and oral levels of Streptococcus mutans and Streptococcus sobrinus in children aged 5–11 years with GERD symptoms, compared to healthy controls. The findings revealed no statistically significant differences in dmft, DMFT, or the combined dmft + DMFT scores between children with GERD and healthy children. Additionally, no significant correlation was observed between GERD scores and the dmft/DMFT indices. Despite a significant relationship between the number of cariogenic microorganisms (S. mutans and S. sobrinus ) and GERD symptoms in this study, the results did not support a direct link between GERD and dental caries. This finding aligns with the multifactorial nature of dental caries etiology, where factors such as socioeconomic status, personal hygiene, and dietary habits play pivotal roles [ 14 ]. Thus, an increased count of cariogenic microorganisms does not necessarily correlate with a higher prevalence of dental caries. Establishing a definitive relationship between GERD and dental caries remains challenging due to inconsistent findings in previous studies, which have reported contradictory results on this topic [ 7 , 15 – 19 ]. Similar to the findings of this study, several investigations have reported no association between GERD symptoms and an increased risk of dental caries [ 6 , 20 , 21 ]. For example, Mahboobi et al. found no significant relationship between GERD and dental caries indices in a large adult population [ 22 ]. Similarly, Muñoz et al. observed no correlation between GERD and dental caries in adults [ 20 ]. In contrast, other studies have suggested that GERD may elevate the risk of dental caries due to changes in saliva composition, reduced salivary flow, and alterations in immune response [ 15 – 17 ]. For instance, Ersin et al. demonstrated that children with GERD were at a higher risk of developing dental caries compared to healthy children [ 23 ]. Given the complexity of caries mechanisms, it has been suggested that evaluating the relationship between GERD and dental caries requires more than just an assessment of symptoms and caries indices. Comprehensive evaluations, including medical history, dietary habits, occupational history, dental history, and oral hygiene practices, are essential for a more accurate understanding of this relationship [ 9 ]. Furthermore, methodological differences in existing studies may partially explain the observed discrepancies in results. These differences include variations in the age groups studied, the stages of GERD assessed, and the research methodologies employed [ 15 – 17 ]. As a result, determining the precise nature of the GERD-dental caries relationship in children remains challenging and warrants further investigation [ 6 ]. Another contributing factor to inconsistencies in study findings is the experience level of the examiners. Accurate dental assessments are highly dependent on the examiner's expertise, which can vary across studies [ 24 , 25 ]. Interestingly, discrepancies in the GERD-dental caries association have been found to be more pronounced in children than in adults, suggesting that pediatric populations may require more specialized attention. This highlights the need for more rigorous and detailed studies specifically focusing on children to better understand the potential link between GERD and dental caries in this age group [ 26 , 27 ]. In this study, no significant relationship was observed between age and the dmft/DMFT indices or their combined score in children with GERD symptoms. However, the limited sample size within each age group may have restricted the ability to establish precise age-related correlations. Unfortunately, no comparable studies examining the relationship between age and these indices in GERD patients were identified, making it difficult to draw definitive conclusions regarding the influence of age on caries development in this population. A notable finding in this study was the higher dmft index compared to the DMFT index, suggesting a longer exposure of primary teeth to cariogenic factors than permanent teeth. Furthermore, children with GERD exhibited significantly higher counts of S. mutans and S. sobrinus compared to healthy children. A direct and statistically significant association was also found between GERD scores and the bacterial counts of these microorganisms. These findings are consistent with those of Ersin et al., who observed higher levels of cariogenic bacteria in the mouths of children with GERD. Specifically, 84% of GERD-affected children had bacterial counts exceeding 10^5 CFU/ml, compared to only 41% in healthy controls. This underscores the potential link between GERD and increased bacterial load in the oral cavity, which may contribute to the caries risk in affected children [ 23 ]. Conversely, some studies have reported that GERD is associated with reduced S. mutans counts, potentially lowering the risk of dental caries. These studies have suggested that the acidic environment caused by GERD might inhibit the growth of these bacteria [ 7 , 18 , 19 ]. For instance, one study found a lower prevalence of Lactobacillus and Streptococcus species in GERD patients compared to controls, a finding that contrasts with the results of the present study, where higher bacterial counts were observed in children with GERD [ 7 ]. Given the acidogenic and aciduric nature of S. mutans and S. sobrinus , their increased presence in individuals with GERD symptoms, as observed in this study, aligns with previous findings that highlight the acidic salivary pH in GERD patients [ 28 , 29 ]. The acidic environment resulting from gastric reflux may create conditions conducive to the growth and proliferation of these cariogenic bacteria, which thrive in low pH settings. This suggests that GERD-related changes in oral pH could play a role in promoting bacterial colonization and, potentially, the development of dental caries in affected individuals. Lastly, this study demonstrated that the association between GERD scores and bacterial counts was statistically significant only in children aged 8 years or younger. Unfortunately, no previous studies were found that specifically examined the impact of age on the relationship between S. mutans and S. sobrinus counts and GERD. This finding suggests that age may influence the microbial dynamics in the oral cavity in the context of GERD, highlighting the need for further research to explore age-specific differences in this relationship. Understanding these dynamics could provide insights into the age-related variations in caries risk and help tailor more effective preventive strategies for children with GERD. Conclusion The findings of this study indicate that while gastroesophageal reflux disease (GERD) was associated with an increase in the number of cariogenic bacteria in the oral cavity, it had no observable impact on the rate of dental caries. These results underscore the significance of microbial factors in the relationship between GERD and oral health, suggesting that the increased presence of S. mutans and S. sobrinus may be a contributing factor. However, the overall effects of GERD on dental caries remain inconclusive. The complexities of caries development, along with various influencing factors such as age, oral hygiene, and dietary habits, necessitate further, more detailed investigations to fully understand the potential impact of GERD on dental well-being. Declarations Acknowledgments The authors express their sincere gratitude and appreciation to the parents of the children for their cooperation in participating in the study and vice-chancellor for Research and Technology of Babol University of Medical Sciences. Author contributions Conceptualization: [AB and MG]; Methodology: [MG and MED]; Data curation [AB and SMT]; Formal data analysis: [HG]; Writing – original draft preparation [AB]; Reviewing and editing [MG, MED and MH]. All authors read and approved the final manuscript. Funding statement This study was supported by vice-chancellor for Research and Technology of Babol University of Medical Sciences. Data availability statement The data is available upon reasonable request from the corresponding author. Ethics approval and consent to participate The study protocol was approved by Research Ethics Committee of Babol University of Medical Sciences (IR.MUBABOL.REC.1402.012) . The study was conducted in accordance with the principles of the Declaration of Helsinki. Written formal informed consent was obtained from children’s parents or legal guardians Conflict of Interest Disclosure The authors declare no potential conflict of interest with respect to the authorship and/or publication of this paper. Consent for publication : Not applicable References Kumar KSS, Mungara J, Venumbaka NR, Vijayakumar P, Karunakaran D. Oral manifestations of gastroesophageal reflux disease in children: A preliminary observational study. J Indian Soc Pedod Prev Dent. 2018;36(2):125–129. doi:10.4103/JISPPD.JISPPD_1182_17 Poddar U. Gastroesophageal reflux disease (GERD) in children. Paediatr Int Child Health. 2019;39(1):7–12. doi:10.1080/20469047.2018.1489649 Sounah SA, Madfa AA. Correlation between dental caries experience and the level of Streptococcus mutans and lactobacilli in saliva and carious teeth in a Yemeni adult population. BMC Res Notes. 2020;13:1–6. Khoroushi M, Khorasgani MR, Aliasghari A. 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Ghasempour","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBUlEQVRIiWNgGAWjYJACZiS2BAM/AwMbiVokG0jUwsBgcICAFt32A8yvC2rq5HRnNx+TrmCwyDe+kfzswYcKBnl+sQNYtZidSWCznnHssLHZnWNpkmcYJCy33UgzN5xxhsFw5uwE7FoOJLAZ87AdSNx2I8cM6A0JA7MbCWbSvG0MCQa3cWg5/wCo5V9dPVyL8Yz0b/i13EhgfszbxpxgBtNiIJFDwJYbD9iYefsOG267cyzZEqRF4sybMskZZyRw++V8AvNnnm918ma3mw/ebGCoM+BvT98m8aHCRp5fGrsWBgb+bxJgGkQy/gMSAgkwLk7A/IEBRQ3/AXyqR8EoGAWjYAQCAMJJWJTszMRqAAAAAElFTkSuQmCC","orcid":"","institution":"Babol University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Maryam","middleName":"","lastName":"Ghasempour","suffix":""}],"badges":[],"createdAt":"2026-01-30 16:23:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8743252/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8743252/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107317591,"identity":"ec02871a-afae-4663-b489-894e3d4a74ef","added_by":"auto","created_at":"2026-04-20 09:58:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":121963,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of dmft scores based on bacterial growth, by study group.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8743252/v1/974aa9447457ed26058ef72b.png"},{"id":107317593,"identity":"b66c1582-0f45-4ad4-9ff7-b8bea1da12b1","added_by":"auto","created_at":"2026-04-20 09:58:49","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":125587,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of DMFT scores based on bacterial growth, by study group.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8743252/v1/f09f1933763750d50cce04f0.png"},{"id":107317498,"identity":"9399b62e-667c-4ba2-bbd3-162fad2f7d8f","added_by":"auto","created_at":"2026-04-20 09:58:36","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":125695,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of dmft+DMFT scores based on bacterial growth, by study group.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8743252/v1/d0482409a112122446d5adaa.png"},{"id":107317672,"identity":"15ce9b13-5f5c-4adf-b082-ba0309d6e76d","added_by":"auto","created_at":"2026-04-20 09:58:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":757947,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8743252/v1/7ef510fb-d559-4dff-b690-7e88893aaaea.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Association Between Gastroesophageal Reflux Disease (GERD) Symptoms, Dental Health, and Cariogenic Microorganisms in the Oral Cavities of Children","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGeneral health is closely linked to oral and dental health. As part of the digestive system, the oral cavity can reflect underlying gastrointestinal disorders such as celiac disease, gastroesophageal reflux disease (GERD), and inflammatory bowel diseases [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Gastroesophageal reflux (GER) is a normal physiological process that occurs several times daily in healthy individuals, including both children and adults. It involves the involuntary passage of stomach contents into the esophagus [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. However, GERD refers to the pathological symptoms and complications arising from GER, typically due to the impaired function of the lower esophageal sphincter, which fails to prevent the backflow of stomach contents into the esophagus [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e\u003cem\u003eStreptococcus mutans\u003c/em\u003e and \u003cem\u003eStreptococcus sobrinus\u003c/em\u003e are widely recognized as the primary etiological agents of dental caries in humans. Extensive research conducted over several decades has established a strong association between the salivary levels of these bacteria and the onset of dental caries [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Alterations in the microbial composition of the tongue, coupled with an overgrowth of S. mutans in dental plaque, indicate the presence of an oral environment that may favor the development of dental caries. While a direct causal relationship between changes in the tongue's microbial flora and the onset of caries has yet to be definitively established, the strong correlation between the proportion of commensal bacteria in the tongue microbiome and salivary levels of S. mutans suggests a potential link [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo date, only a limited number of studies have examied the association between GERD and dental caries, and their findings have been inconsistent. For example, S\u0026icirc;mpălean et al. found no significant effect of GERD on dental caries incidence [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In contrast, Corr\u0026ecirc;a et al. reported a negative relationship between GERD and dental caries [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Gaining a clearer understanding of this relationship could be crucial for enhancing oral hygiene practices and preventing the onset of dental caries [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven the acidic nature of gastric reflux contents and the enhanced growth of \u003cem\u003eS. mutans\u003c/em\u003e and \u003cem\u003eS. sobrinus\u003c/em\u003e in acidic environments, the present study aimed to investigate the relationship between the dmft/DMFT index and oral levels of \u003cem\u003eS. mutans\u003c/em\u003e and \u003cem\u003eS. sobrinus\u003c/em\u003e in children with gastroesophageal reflux disease (GERD), compared to healthy controls.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis case-control study included 69 children aged 5 to 11 years, 32 with GERD and 37 healthy controls who visited a specialized pediatric gastroenterology and hepatology clinic. The sample size was calculated based on similar studies [9], using a 95% confidence level (\u0026alpha; = 0.05) and 80% statistical power (\u0026beta; = 0.2), with the following formula:\u003c/p\u003e\n\u003cp\u003e\u003cimg 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\"\u003e\u003c/p\u003e\n\u003cp\u003ewhere: S1=2.5, S2=1.3, and d=1.5\u003c/p\u003e\n\u003cp\u003eAfter obtaining written informed consent from the parents, the children were evaluated. The diagnosis of GERD was determined using the Gastroesophageal Reflux Disease Assessment in Pediatrics (GASP-Q) questionnaire. Children with a total symptom score (CSS) of \u0026ge;16 were evaluated as having GERD [10].\u003c/p\u003e\n\u003cp\u003eDental status was assessed using the dmft/DMFT index, which measures decayed, missing, and filled teeth. Evaluations were conducted using a dental mirror and probe under natural room light.\u003c/p\u003e\n\u003cp\u003eOral samples were collected with sterile cotton swabs from the tongue and buccal mucosa. Participants were instructed to refrain from eating, drinking, brushing their teeth, or using mouthwash for at least 30 minutes before sampling. Swabs were taken from the anterior two-thirds of the dorsal surface of the tongue and the buccal grooves of both the upper and lower jaws, with each side swabbed for 10 seconds.\u003c/p\u003e\n\u003cp\u003eSerial dilutions of the samples were prepared, and \u003cem\u003eS. mutans\u003c/em\u003e and \u003cem\u003eS. sobrinus\u003c/em\u003e were cultured using the spread plate method on Mitis Salivarius Bacitracin Agar and Blood Agar containing sheep blood. The cultures were incubated at 37\u0026deg;C for 24 hours in a candle jar. Suspected colonies were identified macroscopically and microscopically, and colony counts were expressed in CFU/mL [11-13].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analysis was performed using SPSS software (version 26.0; IBM Corp., Armonk, NY, USA). The normality of the data was assessed using the Kolmogorov-Smirnov test. Independent t-tests and chi-square tests were used to compare groups. Pearson correlation coefficients were calculated to assess relationships among variables, and logistic regression was used to evaluate the association between variables and outcomes. A significance level of P \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the characteristics of the study participants in the GERD and control groups. No statistically significant differences were observed in age or sex distribution between the case and control groups (P\u0026thinsp;=\u0026thinsp;0.379 and P\u0026thinsp;=\u0026thinsp;0.126, respectively).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Variables Studied Between the Case and Control Groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChildren with GERD\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHealthy Children\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;37)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;69)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.44\u0026thinsp;\u0026plusmn;\u0026thinsp;1.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.03\u0026thinsp;\u0026plusmn;\u0026thinsp;1.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.379*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.22\u0026thinsp;\u0026plusmn;\u0026thinsp;1.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eMale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (43.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23 (62.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.126**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e37 (53.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (56.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (37.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32 (46.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGERD Score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e128.38\u0026thinsp;\u0026plusmn;\u0026thinsp;61.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e59.54\u0026thinsp;\u0026plusmn;\u0026thinsp;76.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003edmft\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.78\u0026thinsp;\u0026plusmn;\u0026thinsp;5.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.16\u0026thinsp;\u0026plusmn;\u0026thinsp;4.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.732*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.99\u0026thinsp;\u0026plusmn;\u0026thinsp;4.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDMFT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.41\u0026thinsp;\u0026plusmn;\u0026thinsp;1.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.089*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.03\u0026thinsp;\u0026plusmn;\u0026thinsp;1.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003edmft\u0026thinsp;+\u0026thinsp;DMFT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.16\u0026thinsp;\u0026plusmn;\u0026thinsp;5.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.86\u0026thinsp;\u0026plusmn;\u0026thinsp;4.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.41*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBacterial Count (CFU/mL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.1 \u0026times; 10⁶ \u0026plusmn; 5.6 \u0026times; 10⁶\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.5 \u0026times; 10⁵ \u0026plusmn; 3.2 \u0026times; 10⁵\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.0 \u0026times; 10⁶ \u0026plusmn; 4.3 \u0026times; 10⁶\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e* Independent samples t-test **Chi-square test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe mean GERD score in children with GERD was 128.38\u0026thinsp;\u0026plusmn;\u0026thinsp;61.14. No significant differences were observed between the groups for the mean dmft, DMFT, and combined dmft\u0026thinsp;+\u0026thinsp;DMFT scores (P\u0026thinsp;=\u0026thinsp;0.732, P\u0026thinsp;=\u0026thinsp;0.089, and P\u0026thinsp;=\u0026thinsp;0.41, respectively). However, bacterial counts of \u003cem\u003eS. mutans\u003c/em\u003e and \u003cem\u003eS. sobrinus\u003c/em\u003e were significantly higher in children with GERD than in healthy children (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\n\u003ch3\u003eDistribution of dmft and DMFT Scores Based on Bacterial Growth\u003c/h3\u003e\n\u003cp\u003eThe distribution of dmft scores according to bacterial growth in culture is shown for each study group in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. As shown, bacterial growth was lower in healthy children compared to GERD. Additionally, in children with GERD, higher bacterial growth was associated with higher dmft scores.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAs shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, bacterial growth was significantly lower in healthy children than children with GERD. This suggests a potential correlation between increased bacterial growth and higher DMFT scores in children with GERD.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the combined dmft\u0026thinsp;+\u0026thinsp;DMFT scores based on bacterial growth in culture. As shown in the figure, bacterial growth was significantly lower in healthy children compared to children with GERD. In the GERD group, higher bacterial growth was associated with higher combined dmft\u0026thinsp;+\u0026thinsp;DMFT scores, suggesting a relationship between increased bacterial growth and the severity of dental caries.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eAssociation Between GERD and dmft, DMFT, and dmft + DMFT Indices in Children with GERD\u003c/h3\u003e\n\u003cp\u003eThe relationship between GERD scores and the dmft, DMFT, and combined dmft\u0026thinsp;+\u0026thinsp;DMFT indices was analyzed using linear regression and scatter plots. No statistically significant correlation was found between GERD scores and dmft (Beta\u0026thinsp;=\u0026thinsp;0.002, P\u0026thinsp;=\u0026thinsp;0.986), DMFT (Beta\u0026thinsp;=\u0026thinsp;0.179, P\u0026thinsp;=\u0026thinsp;0.140), or the combined dmft\u0026thinsp;+\u0026thinsp;DMFT (Beta\u0026thinsp;=\u0026thinsp;0.065, P\u0026thinsp;=\u0026thinsp;0.597). These results remained statistically insignificant even after adjusting for the children's ages (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\n\u003ch3\u003eAssociation Between GERD and Bacterial Counts in Children with GERD\u003c/h3\u003e\n\u003cp\u003eA significant positive association was found between GERD scores and bacterial counts in culture, as indicated by linear regression analysis (Beta\u0026thinsp;=\u0026thinsp;0.457, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This association remained statistically significant even after adjusting for age (Beta\u0026thinsp;=\u0026thinsp;0.482, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cb\u003eAssociation Between GERD and Factors of dmft, DMFT, dmft\u0026thinsp;+\u0026thinsp;DMFT indices, and Bacterial Counts by Age Groups in Children with GERD\u003c/b\u003e \u003c/p\u003e \u003cp\u003eChildren were categorized into two age groups: 8 years and younger, and older than 8 years. The relationships between GERD scores and dmft, DMFT, dmft\u0026thinsp;+\u0026thinsp;DMFT indices, and bacterial counts were analyzed separately for these age groups. The results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003eThe Relationships Between GERD Scores and dmft, DMFT, dmft\u0026thinsp;+\u0026thinsp;DMFT Indices, and Bacterial Counts by Age Groups\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFactor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eAge\u0026thinsp;\u0026le;\u0026thinsp;8 Years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eAge\u0026thinsp;\u0026gt;\u0026thinsp;8 Years\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBeta\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBeta\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003edmft\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.219\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.158\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.459\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDMFT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.066\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.675\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.151\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.749\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003edmft\u0026thinsp;+\u0026thinsp;DMFT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.224\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.769\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBacterial Count (CFU/mL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.645\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.572\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA significant positive association was found between GERD scores and bacterial counts only in the 8 years and younger (Beta\u0026thinsp;=\u0026thinsp;0.645, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No statistically significant associations were observed in the older age group (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case-control study explored the association between dmft/DMFT indices and oral levels of \u003cem\u003eStreptococcus mutans\u003c/em\u003e and \u003cem\u003eStreptococcus sobrinus\u003c/em\u003e in children aged 5\u0026ndash;11 years with GERD symptoms, compared to healthy controls. The findings revealed no statistically significant differences in dmft, DMFT, or the combined dmft\u0026thinsp;+\u0026thinsp;DMFT scores between children with GERD and healthy children. Additionally, no significant correlation was observed between GERD scores and the dmft/DMFT indices.\u003c/p\u003e \u003cp\u003eDespite a significant relationship between the number of cariogenic microorganisms \u003cem\u003e(S. mutans\u003c/em\u003e and \u003cem\u003eS. sobrinus\u003c/em\u003e) and GERD symptoms in this study, the results did not support a direct link between GERD and dental caries. This finding aligns with the multifactorial nature of dental caries etiology, where factors such as socioeconomic status, personal hygiene, and dietary habits play pivotal roles [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Thus, an increased count of cariogenic microorganisms does not necessarily correlate with a higher prevalence of dental caries. Establishing a definitive relationship between GERD and dental caries remains challenging due to inconsistent findings in previous studies, which have reported contradictory results on this topic [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR16 CR17 CR18\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSimilar to the findings of this study, several investigations have reported no association between GERD symptoms and an increased risk of dental caries [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. For example, Mahboobi et al. found no significant relationship between GERD and dental caries indices in a large adult population [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Similarly, Mu\u0026ntilde;oz et al. observed no correlation between GERD and dental caries in adults [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. In contrast, other studies have suggested that GERD may elevate the risk of dental caries due to changes in saliva composition, reduced salivary flow, and alterations in immune response [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. For instance, Ersin et al. demonstrated that children with GERD were at a higher risk of developing dental caries compared to healthy children [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven the complexity of caries mechanisms, it has been suggested that evaluating the relationship between GERD and dental caries requires more than just an assessment of symptoms and caries indices. Comprehensive evaluations, including medical history, dietary habits, occupational history, dental history, and oral hygiene practices, are essential for a more accurate understanding of this relationship [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Furthermore, methodological differences in existing studies may partially explain the observed discrepancies in results. These differences include variations in the age groups studied, the stages of GERD assessed, and the research methodologies employed [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. As a result, determining the precise nature of the GERD-dental caries relationship in children remains challenging and warrants further investigation [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnother contributing factor to inconsistencies in study findings is the experience level of the examiners. Accurate dental assessments are highly dependent on the examiner's expertise, which can vary across studies [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Interestingly, discrepancies in the GERD-dental caries association have been found to be more pronounced in children than in adults, suggesting that pediatric populations may require more specialized attention. This highlights the need for more rigorous and detailed studies specifically focusing on children to better understand the potential link between GERD and dental caries in this age group [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, no significant relationship was observed between age and the dmft/DMFT indices or their combined score in children with GERD symptoms. However, the limited sample size within each age group may have restricted the ability to establish precise age-related correlations. Unfortunately, no comparable studies examining the relationship between age and these indices in GERD patients were identified, making it difficult to draw definitive conclusions regarding the influence of age on caries development in this population.\u003c/p\u003e \u003cp\u003eA notable finding in this study was the higher dmft index compared to the DMFT index, suggesting a longer exposure of primary teeth to cariogenic factors than permanent teeth. Furthermore, children with GERD exhibited significantly higher counts of \u003cem\u003eS. mutans\u003c/em\u003e and \u003cem\u003eS. sobrinus\u003c/em\u003e compared to healthy children. A direct and statistically significant association was also found between GERD scores and the bacterial counts of these microorganisms. These findings are consistent with those of Ersin et al., who observed higher levels of cariogenic bacteria in the mouths of children with GERD. Specifically, 84% of GERD-affected children had bacterial counts exceeding 10^5 CFU/ml, compared to only 41% in healthy controls. This underscores the potential link between GERD and increased bacterial load in the oral cavity, which may contribute to the caries risk in affected children [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eConversely, some studies have reported that GERD is associated with reduced \u003cem\u003eS. mutans\u003c/em\u003e counts, potentially lowering the risk of dental caries. These studies have suggested that the acidic environment caused by GERD might inhibit the growth of these bacteria [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. For instance, one study found a lower prevalence of \u003cem\u003eLactobacillus\u003c/em\u003e and \u003cem\u003eStreptococcus species\u003c/em\u003e in GERD patients compared to controls, a finding that contrasts with the results of the present study, where higher bacterial counts were observed in children with GERD [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven the acidogenic and aciduric nature of \u003cem\u003eS. mutans\u003c/em\u003e and \u003cem\u003eS. sobrinus\u003c/em\u003e, their increased presence in individuals with GERD symptoms, as observed in this study, aligns with previous findings that highlight the acidic salivary pH in GERD patients [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The acidic environment resulting from gastric reflux may create conditions conducive to the growth and proliferation of these cariogenic bacteria, which thrive in low pH settings. This suggests that GERD-related changes in oral pH could play a role in promoting bacterial colonization and, potentially, the development of dental caries in affected individuals.\u003c/p\u003e \u003cp\u003eLastly, this study demonstrated that the association between GERD scores and bacterial counts was statistically significant only in children aged 8 years or younger. Unfortunately, no previous studies were found that specifically examined the impact of age on the relationship between \u003cem\u003eS. mutans\u003c/em\u003e and \u003cem\u003eS. sobrinus\u003c/em\u003e counts and GERD. This finding suggests that age may influence the microbial dynamics in the oral cavity in the context of GERD, highlighting the need for further research to explore age-specific differences in this relationship. Understanding these dynamics could provide insights into the age-related variations in caries risk and help tailor more effective preventive strategies for children with GERD.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e The findings of this study indicate that while gastroesophageal reflux disease (GERD) was associated with an increase in the number of cariogenic bacteria in the oral cavity, it had no observable impact on the rate of dental caries. These results underscore the significance of microbial factors in the relationship between GERD and oral health, suggesting that the increased presence of \u003cem\u003eS. mutans\u003c/em\u003e and \u003cem\u003eS. sobrinus\u003c/em\u003e may be a contributing factor. However, the overall effects of GERD on dental caries remain inconclusive. The complexities of caries development, along with various influencing factors such as age, oral hygiene, and dietary habits, necessitate further, more detailed investigations to fully understand the potential impact of GERD on dental well-being.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors express their sincere gratitude and appreciation to the parents of the children for their cooperation in participating in the study and vice-chancellor for Research and Technology of Babol University of Medical Sciences.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: [AB and MG]; Methodology: [MG and MED]; Data curation [AB and SMT]; Formal data analysis: [HG]; Writing \u0026ndash; original draft preparation [AB]; Reviewing and editing [MG, MED and MH]. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by vice-chancellor for Research and Technology of Babol University of Medical Sciences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data is available upon reasonable request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by Research Ethics Committee of Babol University of Medical Sciences (IR.MUBABOL.REC.1402.012)\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e The study was conducted in accordance with the principles of the Declaration of Helsinki. Written formal informed consent was obtained from children\u0026rsquo;s parents\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eor legal guardians\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Disclosure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no potential conflict of interest with respect to the authorship and/or publication of this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: Not applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eKumar KSS, Mungara J, Venumbaka NR, Vijayakumar P, Karunakaran D. Oral manifestations of gastroesophageal reflux disease in children: A preliminary observational study. J Indian Soc Pedod Prev Dent. 2018;36(2):125\u0026ndash;129. doi:10.4103/JISPPD.JISPPD_1182_17\u003c/li\u003e\n \u003cli\u003ePoddar U. Gastroesophageal reflux disease (GERD) in children. 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Pediatr Dent. 2006;28(3):279\u0026ndash;284.\u003c/li\u003e\n \u003cli\u003eTolia V, Vandenplas Y. Systematic review: the extra-oesophageal symptoms of gastro-oesophageal reflux disease in children. Aliment Pharmacol Ther. 2009;29(3):258\u0026ndash;72.\u003c/li\u003e\n \u003cli\u003ePace F, Pallotta S, Tonini M, Vakil N, Bianchi Porro G. Systematic review: gastro-oesophageal reflux disease and dental lesions. Aliment Pharmacol Ther. 2008;27(12):1179\u0026ndash;85.\u003c/li\u003e\n \u003cli\u003eLechien JR, Calvo-Henriquez C, Chiesa-Estomba CM, et al. Reflux and dental disorders in the pediatric population: A systematic review. Int J Pediatr Otorhinolaryngol. 2020;136:110166.\u003c/li\u003e\n \u003cli\u003eFirouzei MS, Khazaei S, Afghari P, Savabi G, Savabi O, Keshteli AH, et al. Gastroesophageal reflux disease and tooth erosion: SEPAHAN systematic review no. 10. Dent Res J. 2011;8(Suppl1):S9.\u003c/li\u003e\n \u003cli\u003eBaker J, Faustoferri R, Quivey Jr R. Acid-adaptive mechanisms of \u003cem\u003eStreptococcus mutans\u003c/em\u003e \u0026mdash; the more we know, the more we don\u0026rsquo;t. Mol Oral Microbiol. 2017;32(2):107.\u003c/li\u003e\n \u003cli\u003eLemos JA, Palmer SR, Zeng L, et al. The biology of \u003cem\u003eStreptococcus mutans\u003c/em\u003e. Microbiol Spectr. 2019;7(1):gpp3-0051-2018.\u003cstrong\u003e\u003cspan dir=\"RTL\"\u003e\u003c/span\u003e\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Gastroesophageal Reflux, Dental Caries, Oral Hygiene, Streptococcus mutans, Streptococcus sobrinus","lastPublishedDoi":"10.21203/rs.3.rs-8743252/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8743252/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The acidic nature of gastric refluxate, combined with the enhanced proliferation of \u003cem\u003eStreptococcus mutans\u003c/em\u003e and \u003cem\u003eStreptococcus sobrinus\u003c/em\u003e in acidic environments, underscores the potential impact of gastroesophageal reflux disease (GERD) on oral health. This study aimed to explore the relationship between dental health status and microbial load in the oral cavity of children diagnosed with GERD symptoms, in comparison to compared with healthy controls.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This case-control study involved 32 children with GERD and 37 healthy children, aged 5 to 11 years. GERD symptoms were assessed using the GERD Assessment of Symptoms in Pediatrics Questionnaire (GASP-Q). Dental health was evaluated using the decayed, missing, and filled teeth (dmft/DMFT) index. Microbial load was measured by sampling the tongue and cheeks with sterile cotton swabs, followed by the quantification of \u003cem\u003eS. mutans\u003c/em\u003e and \u003cem\u003eS. sobrinus\u003c/em\u003e. Statistical analyses were performed using Chi-square tests, independent T-tests, Pearson correlation coefficients, and logistic regression with SPSS software, at a significance level of 0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The mean age of the children was 8.22 ± 1.92 years. No significant differences were observed between the case and control groups in terms of mean age (P = 0.379) or sex distribution (P = 0.126). There was no significant difference in the dmft/DMFT index scores between the two groups (P = 0.410). However, the mean bacterial count was significantly higher in the GERD group compared to the control group (P \u0026lt; 0.001). A significant linear relationship was found between GERD symptoms and bacterial load in children aged 8 years or younger (Beta = 0.645, P \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e While GERD was associated with an increased levels of cariogenic bacteria in the oral cavity, no significant effect on dental caries rates was observed.\u003c/p\u003e","manuscriptTitle":"Association Between Gastroesophageal Reflux Disease (GERD) Symptoms, Dental Health, and Cariogenic Microorganisms in the Oral Cavities of Children","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-20 09:57:42","doi":"10.21203/rs.3.rs-8743252/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-06T15:12:39+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-06T08:10:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-01T07:49:40+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-27T08:18:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-26T19:21:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"320154899737281572922747318401844812621","date":"2026-04-26T10:23:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"223521409675711522183299629510679210545","date":"2026-04-23T11:58:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"319315007982156532807516637884254577905","date":"2026-04-22T05:16:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"191571329491368885293229774385112822357","date":"2026-04-21T11:14:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-10T12:38:02+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-27T05:58:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-06T11:11:30+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-05T18:26:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2026-02-05T18:16:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f80b1b55-295f-4ade-add3-65221db849d6","owner":[],"postedDate":"April 20th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-06T15:12:39+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-06T08:10:12+00:00","index":62,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-01T07:49:40+00:00","index":60,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-06T15:24:36+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-20 09:57:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8743252","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8743252","identity":"rs-8743252","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}