Dental erosion: possible approaches

to prevention and control

B.T. Amaechi
a,
*
, S.M. Higham
b
a
Cariology Unit, Department of Community Dentistry, University of Texas Health Science Centre
at San Antonio, MC 7917, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900, USA
b
Cariology Group, Department of Clinical Dental Sciences, School of Dentistry, Edwards Building,
Daulby Street, Liverpool L69 3GN, UK
Received 1 October 2004; accepted 4 October 2004
KEYWORDS
Dental erosion;
Aetiology;
Prevention;
Protection;
Erosive agents;
Oral health;
Control
Summary Objectives. To discuss the key elements for establishment of a
preventive programme for dental erosion.
Data and sources. The data discussed are primarily based on published scientic
studies and reviews fromcase reports, clinical trials, epidemiological, cohort, animal,
in vitro and in vivo studies. References have been traced manually or by MEDLINE
w
.
Study selection. The aetiology, pathogenesis and modifying factors of dental
erosion were reviewed. Strategies to either prevent the occurrence or limit the
damage of dental erosion or protect the remaining tooth tissues from further erosive
destruction were reviewed and discussed. These includes: (A) measures to (1)
enhance remineralisation and acid resistance of enamel surface softened by erosive
challenge, (2) reduce the erosive potential of acidic products, (3) enhance salivary
ow, (4) protect and restore erosively damaged tooth, and (5) provide mechanical
protection against erosive challenge. (B) Health education geared towards (1)
diminution of frequency of intake of dietary acids, and (2) change of habits and
lifestyles that predispose teeth to erosion development.
Conclusions. It may be easier to gain patients compliance with the advice that
immediately following an acidic challenge, a remineralising agent, such as uoride
mouthrinses, uoride tablets, uoride lozenges or dairy milk, should be administered
to enhance rapid remineralisation of the softened tooth surface as well as serve as a
mouth refresher, or an alternative, a neutralising solution should be used. Effective
counselling on erosion preventive regimes should involve all healthcare personnel,
dentists, doctors, pharmacist, nurses/hygienists and clinical psychologists.
q 2004 Elsevier Ltd. All rights reserved.
Introduction
Dental erosion, otherwise known as erosive tooth
wear, is the loss of dental hard tissue through either
chemical etching and dissolution by acids of non-
bacterial origin or chelation. The occurrence of this
Journal of Dentistry (2005) 33, 243252
www.intl.elsevierhealth.com/journals/jden
0300-5712/$ - see front matter q 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jdent.2004.10.014
* Corresponding author. Tel.: C1 210 567 3200/3185;
fax: C1 210 567 4587.
E-mail address: amaechi@uthscsa.edu (B.T. Amaechi).
condition was reported as early as the 19th century,
1
andsincethentheincidenceandprevalenceof dental
erosionis increasingly beingreported.
2
This is evident
from prevalence studies conducted in two different
parts of the world within the last decade that showed
the percentage of individual affected by erosion
(Table1) amongvarious agegroups.
37
Especiallywith
the decline in caries ratein some countries, erosion is
now becoming a focus of increasing interest both in
clinical dentistry and research. The management of
dental erosion is an area of clinical practice that is
undoubtedly expanding.
8
The past two decades have
seen numerous investigations and reports on the
prevalence,
2
the aetiology,
9
the pathogenesis and
the modifying factors
1016
of dental erosion. It is now
time for development of a preventive programme to
control the prevalence of this dental destructive
disorder. Therefore, the key elements required for
designing and the achievement of an effective
preventive programme are discussed and rec-
ommended in this paper. These are discussed under
the following headings:
1. Erosion predictorsconditions identied as to
predispose teeth to the development of dental
erosion.
2. Guidelines for prevention and controlrec-
ommendations for preventing and controlling
dental erosion.
3. Guidelines for protectionrecommendations for
the protection of remaining tooth tissues from
further damage and deterioration.
Key elements of an effective preventive
programme
Use of erosion predictors
An important step towards prevention of dental
erosion should be the identication of those
individuals who are at risk of dental erosion.
Evidence based on case reports, clinical trials,
epidemiological, cohort, animal, in vitro and in
vivo studies have described acids that could cause
dental erosion as originating from gastric, dietary or
environmental sources. Based on this fact, certain
factors have been identied as the predictors of
susceptibility to dental erosion.
Medical conditions
Chronic vomiting in eating disorders such as anorexia
and bulimia nervosa, passive regurgitation in gastro-
oesophageal reux disease (GORD) and either
passive regurgitation or chronic vomiting in chronic
alcoholism and binge drinking,
17,18
have all been
associated with repeated direct contact of teeth
with gastric contents, the pH of which can be as low
as 1, resulting to acidic dissolution of dental hard
tissues.
Misuse of acidic dietary products
Frequent and prolonged ingestion of acidic fruits,
fruit juices and acidic beverages has been reported
as causing dental erosion.
9,12
This is observed in
cases such as habitual intake, dieting with citrus
fruits and fruit juices, drinking during strenuous
sporting activities, bed-time use in reservoir feeder
or continuous use in baby bottle feeding as a
comforter. Bed-time baby bottle feeding and GORD
are likely to be more destructive due to decrease in
salivary ow during sleep. Furthermore, deciduous
teeth in vitro have been shown to be one and half
times more susceptible to erosion than permanent
teeth.
12
These practices would lower the pH of the
oral uids for a prolonged period, thus exposing the
teeth to prolonged periods of acidic challenge with
consequent etching and dissolution. It has been
established that the rate of consumption of pure
fruit juices and acidic beverages is increasing
19
as a
consequence of their ease of availability and lack of
expense.
Use of acidic medicaments
Case reports have revealed that acidic medica-
ments prescribed frequently for long periods of
time, predispose teeth to dental erosion.
9,20
Medicaments such as acetylsalicylic acid, ascorbic
acid, liquid hydrochloric acid, iron tonics, acidic
saliva stimulants/substitutes and products with
calcium chelating properties have high erosive
potentials.
Occupation
The occupation of a patient may give a clue as to
his/her susceptibility to dental erosion. Industrial
processing procedures exposing workers to acidic
Table 1 Summary of prevalence studies of dental
erosion.
Age (years) % affected Evidence
14 20 UK Toddlers
Survey
3
45 38 Millward et al.
4
56 52 UK Child Dental
Health Survey
5
11 25 UK Child Dental
Health Survey
5
1114 57 Bartlett et al.
6
2630 30 Lussi et al.
7
4550 42.6 Lussi et al.
7
B.T. Amaechi, S.M. Higham 244
fumes or aerosols as in the case with battery and
fertiliser factories, professional swimming in impro-
perly pH-regulated swimming pools and professional
wine tasting, have all been linked to dental erosion
through several case reports.
9,2123
Use of illegal drugs
Addictive use of certain illegal drugs such as cocaine
and ecstasy is associated with excessive consump-
tion of acidic beverages, due to the side-effects of
dehydration and hyposalivation,
24
thus predisposing
the user to the risk of dental erosion.
Lactovegetarians
Dental erosion has been reported to be common
among lactovegetarians due to an associated hypo-
salivation and high consumption of low-pH foodstuffs
combined with the abrasive effect of the coarse
fresh food.
25
Excessive oral hygiene procedure
Frequent tooth brushing with abrasive dentifrice as
practiced by some health/aesthetic-conscious indi-
viduals may render the tooth surface more suscep-
tible to erosion due to removal of the more
protective highly mineralised outer layer of enamel
surface
26
and reduction of the thickness of the
acquired salivary pellicle, which would adversely
affects its established protective role against dental
erosion.
11
Guidelines for prevention and control
The above erosion predictors highlight the fact that
the elimination of the causative factor may be
difcult since the individuals who are susceptible to
dental erosion might have either psychological or
professional inclinations to the factors predisposing
them to the disorder. This would obviously pose
difculty in obtaining full compliance with preven-
tive advice, even when the causative factor is
identied. However, the following recommen-
dations, if implemented in a preventive programme,
might prevent occurrence, limit the damage, modify
the habit or protect the remaining tooth tissue.
Early diagnosis and monitoring
Patients can barely detect early enamel erosion due
to its smooth and shiny appearance (Fig. 1). Even
when detected, they rarely seek treatment until it
gets to an advanced stage when it either becomes
symptomatic or affects the aesthetics of their teeth.
The responsibility of early detection and initiation of
treatment of dental erosion, therefore, falls on the
dental professionals. In the light of this, the rst and
the most important step in a preventive strategy
would be the development of and training of dental
professionals on techniques for the early diagnosis
and monitoring of the progress of dental erosion.
This would not only permit early institution of
treatment and preventive regimes including health
education and counselling but would also enable the
preventive regimes to be assessed scientically and
quantitatively. There is no diagnostic device avail-
able at present for early clinical detection and
quantication of dental erosion. However, some
indices and techniques have been developed for
continuing monitoring of the lesion status. The
Silicone Index described by Shaw et al.
27
(a silicone
putty impression of the teeth is taken in a sectional
tray), is one of the easiest and most useful methods
of monitoring tooth wear. The Tooth Wear Index of
Smith and Knight,
28
which records the degree of
wear on all tooth surfaces, allows monitoring of the
effectiveness of preventive measures. Serial (refer-
ence) impression casts or study models rec-
ommended by Wickens
29
can be used at follow up
visits for macroscopic comparison with the teeth to
monitor wear. Clinical photographs are obviously
useful for monitoring wear, but the dexterity of the
photographer and ambient conditions such as light
reections affects the quality of the outcome.
Although these indices and techniques are useful
for estimating the extent and pace of the tooth
wear, they are not capable of quantifying the
mineral lost through erosion and the actual depth
of tissue demineralization. Amaechi et al.
14,30
have
shown that the depth of an eroded lesion consists of
the depth of the crater plus the depth of tissue
demineralisation at the base of the lesion (Fig. 2).
It is pertinent to mention that the existence of this
demineralisation pattern described by Amaechi
et al.
14,30
is yet to be shown in naturally occurring
eroded lesions-perhaps due to lack of a device for
in vivo quantication of eroded lesion. However,
at present, the method that is used for this
Figure 1 Facial erosion with smooth and shiny appear-
ance. Courtesy: Professor Adrian Lussi, Univ. Bern,
Switzerland.
Prevention of dental erosion 245
quantication, for in vitro and in situ studies, is
transverse microradiography,
31
so there is still a
need for a system with clinical application.
Once dental erosion is detected, there is a need
for full case history, which should include dietary
history, medical history, dental hygiene habits and
lifestyle history. This would establish the aetiologi-
cal factor, and help in development of individualised
counseling.
Preventive strategies
Following the diagnosis of an early lesion or patients
susceptibility, the following recommendations may
be considered as a damage-limiting as well as
preventive policy.
Treatment of the underlying medical disorders and
diseases. Some patients may not be aware of their
underlying medical condition, but in search of
treatment for the deteriorating condition of their
teeth. Therefore the dentist may be the rst
healthcare professional to detect an underlying
medical disorder.
32,33
Some patients may not recog-
nise their condition as a disorder, especially the
anorexia/bulimia patients, and hence would not
seek medical attention until it starts affecting the
aesthetics, function or comfort of their teeth. Such
patients should be referred to the appropriate
specialist (doctor or clinical psychologist) for proper
treatment of their condition.
Use of a remineralising agent. It is a common
practice among individuals to refresh their mouth by
toothbrushing with dentifrice after vomiting or
regurgitation, as the case with an eating disorder
or chronic alcoholism. Bearing in mind that softening
of tooth surface by acidic challenge decreases its
wear-resistance, thus rendering it more susceptible
to the effects of mechanical abrasion,
34
some
researchers discourage toothbrushing as a means of
refreshing the mouth after an acidic challenge.
Instead, the use of time-delay technique (such as
allowing at least 60 min before brushing) to achieve
remineralisation by saliva alone is advised.
3537
Although a softened enamel surface can be
remineralised with exposure to saliva,
14,30,36
it has
been demonstrated that enamel surface softened by
an erosive agent may be worn by abrasion from
the surrounding oral soft tissues
16
and demastica-
tion,
15,16,3840
before it can be remineralised by
saliva, with consequent loss of tooth tissue softened
by erosion (Figs. 3ac and 4a and b). Moreover, it is
not feasible to obtain patients compliance with a
time-delay technique without the provision of an
alternative mouth refresher. It may be more
acceptable, practicable and easier to gain patients
compliance, if, following an acidic challenge, a
remineralising agent could be administered immedi-
ately to enhance rapid remineralisation of the
softened tooth surface and also serve as a mouth
refresher. It may be advisable for individuals
suffering from GORD to use a remineralising agent
on waking from sleep. Graubart et al.
41
have shown
in vitro that a 4-min pre-treatment of an acid-etched
enamel surface with 2% sodium uoride signicantly
reduced the solubility of the enamel surface, while
the application of sodium uoride solutions immedi-
ately before toothbrushing signicantly reduced
abrasion of eroded dentine in vitro.
42
The reminer-
alisation of the eroded tissue has been reported to
confer a greater resistance to subsequent acid
attack on the affected tooth surfaces.
37,42,43
The concentration of topically applied uoride
required to reduce subsequent demineralisation by
erosion may differ from the recommended concen-
tration for carious lesions, considering the differ-
ences in their pathology, and the fact that uoride is
applied for different purposes in these two con-
ditions. Since an incipient caries lesion is a subsur-
face lesion and the uoride agent needs to
effectively diffuse through a relatively sound surface
layer to remineralise the subsurface lesion, it is
expected that low uoride concentrations applied
frequently would be more suitable for caries.
Imfeld
44
assumed that a high uoride concentrations
may promote the formation of a poorly permeable
remineralised surface layer, thereby blocking
enamel pores and reducing the ion exchange activity
of surface enamel, and ultimately hindering
Figure 2 Early enamel erosion showing lesion with an
erosion crater and subsurface demineralisation X150.
B.T. Amaechi, S.M. Higham 246
the remineralisation of the underlying subsurface
lesion. This is yet to be demonstrated in any study.
Erosion is a surface phenomenon and uoride is
applied primarily to reharden the thin layer of
surface softened enamel or dentine, and it has
been reported that high-concentrated uoride
applications are able to increase abrasion resistance
and decrease the development of erosions in enamel
and dentine
45
Immediate administration of a remineralising
agent can be achieved by the following means:
Use of uoride mouthrinses.
45,46
Fluoride tablets
and uoride lozenges, which have been
demonstrated as effective remineralising agent
for dental caries,
47,48
could be useful for erosion
with their dual functions of direct uoride
provision and stimulation of salivary ow. Stimu-
lation of salivary ow could facilitate rapid
remineralisation of the softened tooth tissue as
this has been shown to increase the potential of
saliva for the remineralisation of a carious
lesion.
49
Increase salivary ow provides calcium
and phosphate as well as an alkaline or neutral
environment necessary for remineralisation; the
buffering capacity and bicarbonate content of
stimulated saliva is higher than that of unstimu-
lated saliva.
45
It is also speculated that saliva
Figure 3 Microradiograph of softened enamel lesion (a) with demineralised surface before intraoral exposure to
saliva. Following intraoral exposure to saliva, the demineralised surface (a) was remineralised (b) in the lesions
protected with an erosion model (Figure 4a), but abraded (c) in the unprotected lesions with consequent loss of tooth
tissue softened by erosion. XZpreviously demineralised surface. YZpreviously nail-varnish-coated sound surface with
varnish worn following intra-oral exposure.
Prevention of dental erosion 247
stimulation would enhance the formation of
acquired salivary pellicle, which has been shown
to protect teeth against erosive attack.
11
Use of diary products (such as fresh milk) have
been shown to reharden softened tooth surface
50
and may be useful following an erosive challenge.
Although remineralisation through cheese eating
and chewing sugar-free gum has been advocated
for dental caries,
49,51
it is considered a potential
risk that abrasion of the softened tooth surface
through cheese mastication and shear forces from
increased movement of the surrounding oral soft
tissues could (theoretically) occur.
Other methods of increasing the resistance of
tooth surface to erosive challenge through reminer-
alisation are as follows:
Periodic professional application of uoride
varnishes or gels can increase the resistance of
the tissue to further erosive attack.
45,46,52,53
It has
been demonstrated that etching of enamel
increases the surface-reactive area, and topically
applied uoride has been shown to accumulate in
demineralised lesions.
45
No difference was found
between uoride varnish and uoride solution in
this respect.
46
Toumba
54
has recently demonstrated the use of
slow-release devices for uoride delivery to high-
risk individuals. These devices, attached to an
upper molar tooth, deliver low levels of uoride
for at least 2 years and may facilitate rapid
remineralisation of eroded enamel or dentine
surfaces.
It has been demonstrated in situ
14
and in vitro
30
that even when erosion has created a crater, the
base of the lesion is hypomineralised and can be
remineralised (Fig. 2). Therefore, regular use of
remineralising agents to protect the teeth against
further erosive dissolution should be rec-
ommended for all individuals susceptible to
dental erosion as described in section on erosion
predictors.
Use of a neutralising agent. As an alternative to a
remineralising agent, sugar-free antacid tablets or a
pinch of sodiumbicarbonate or baking soda dissolved
in some water may be used to neutralise the
acidic oral uid following exposure to acidic chal-
lenge.
55,56,57
As stated above, neutralisation of an
acidic oral uid using chewing gums containing
phosphates, carbonates or urea, which has been
demonstrated
57
may be discouraged due to the risk
of abrasion of the softened tooth surface.
Condition/method of drinking. The temperature of
an acidic drink inuences its erosive potential.
Taking the drink ice-cold reduces its erosive
effect.
12,13
Acidic drinks should be consumed
through a straw since this method of drinking has
been reported to reduce the contact of the teeth
with the erosive agent and enhance the rate of
clearance of the agent from oral cavity.
58,59
The
drink should be swallowed quickly and not sipped
slowly or swished around the mouth.
Use of protective devices. It might be reasonable to
use a close tting occlusal guard at high risk times
such as during sleeping (for GORD patients),
swimming in poorly maintained swimming pool
(for professional swimmers), voluntary vomiting
(for anorexia/bulimia patients) or while on factory
duty (for factory workers). An alkali, such as milk of
magnesia or a neutral uoride gel should be applied
to the tting surface of the guard to neutralize
any acid pooling underneath the appliance and
enhance the remineralisation of the tooth surface.
60
Figure 4 An erosion in situ model. (a) Enamel slabs
bearing a softened enamel lesion showing platform of
composite (arrowed) which submerged the lesion to
protect it from abrasive action of the oral soft tissues.
(b) Illustration of the contact of the model with oral soft
tissue (tongue) and the lesion protection from contact
with soft tissue. 1Zoral soft tissue; 2Zin situ model
cemented on tooth surface; 3Zthe cementing compo-
site; 4Znatural tooth in the mouth.
B.T. Amaechi, S.M. Higham 248
Product modication. The properties of food and
beverages which inuence their erosive potential
includes pH, titratable acidity, type of acid (pK
a
),
calcium chelating properties, concentration of inor-
ganic element (calcium, phosphate and uoride),
physical and chemical properties affecting adher-
ence to the enamel surface and stimulation of
salivary ow.
9
Many steps have been taken to modify
the composition of acidic dietary products with
respect to these properties with the aim of reducing
their erosive potential. Addition of compounds or
mixtures supplying calcium and phosphate salts to
erosive drinks has attracted a major attention, while
addition of citrate, acidulation of the drinks or
reduction of carbonation have all been suggested.
These methods have been found to have an effect on
the avour as well as pH of drinks depending on the
type of salt used and its concentration.
61
Addition of
calcium to a low pH blackcurrant juice drink has
been shown to reduce the erosive effect of the
drink.
62
This is plausible as erosion is not only caused
by acidic dissolution but also by calcium-chelation.
Soluble calcium salts and calcium phosphates should
therefore have an anti-erosive effect by increasing
the calcium concentration gradient within the
immediate environment of the tooth. The addition
of acceptable level of uoride to orange juice drink
signicantly protected against erosion in vitro.
63
Speculations of more substantial uptake of uoride
from uoride-containing fruit drinks than from
uoridated water has also been raised, based on
the action of fruit acids and citrate on the enamel
surface.
64
It has also been speculated that due to the
low pH level (and hence fewer hydroxyl ions) in
acidic drinks, the exchange of enamel hydroxide and
solution uoride might occur more readily during the
drinking process.
65
Health education. The following recommendations
may be considered for the development of an
effective health education programme relating to
prevention of dental erosion
Dental professionals should be proactive in health
education relating to prevention of dental erosion,
as with dental caries. The public and patients should
be informed of the dental implications of the
predisposing factors discussed above. In addition,
patients should be advised on how to prevent or
minimise the problems and the importance of full
compliance with the preventive policies. There is a
need for the dental profession to work closely with
medical colleagues to alert them of the dental
consequences of certain medications and medical
conditions, and how to minimise them.
66
This would
enable the information on preventive regimes to
be passed to the patients at an early stage before
the damage is done. Pharmacologists, on the other
hand, should be urged to include, in the list of side-
effects, the potential dental consequences of some
medications when used under certain conditions (for
instance, frequent and prolonged use) and how to
minimise such side-effects (such as rinsing with a
remineralising agent while using the medication).
Patients with such disorders or prescriptions that
may predispose them to erosion should be advised by
all healthcare personnel involved in their manage-
ment (doctors, clinical psychologists and pharma-
cists) to visit their dentist for regular dental
examination. This would enable early detection of
dental erosion and appropriate management could
be instituted immediately.
Dental school curricula should include training on
the causes and consequences of dental erosion, and
how to prevent or minimise it. The students/dentist
should pass on this information to the patients and
general public, as part of dental health education.
Counseling should be individualised and relate to
the observed aetiological factor. The following key
points may be considered as a guide:
The hazard of brushing immediately following
acidic challenge should be stressed and advice
given for the use of either remineralising or
neutralising agents or milk, as an alternative to
brushing.
The need for change of attitude towards acidic
dietary drinks and fruits should be explained. The
consequences of frequent and prolonged intake of
these foodstuffs should be explained and advice
given on the importance of reduction in amount
and frequency.
The intake of acidic foods or drinks immediately
before bed should be avoided.
The practice of continuous or bedtime baby bottle
feeding with baby fruit juices as a means of
comforting a child should be discouraged, with
explanation of the dental consequences.
Advice should be given on health and safety at
work with the aim of preventing erosion. Use of a
protective guard while on duty might be advised.
The guard should be used with the tting surface
smeared with an alkali (such as milk of magnesia)
or a neutral uoride gel to neutralize any acid
pooling underneath the appliance.
High-risk individuals should be urged to change
their oral hygiene procedures; using a low
abrasive toothbrush (soft brush) with a high
uoride- or bicarbonate-containing toothpaste
with low abrasivity. Toothbrushes are marked
with different bristle textures (soft, medium,
hard brush), and it has been demonstrated that,
with the same dentifrice, the rate and degree of
Prevention of dental erosion 249
enamel and dentine abrasion varies with the
texture of the bristle and the shape of bristle
cut.
6769
Guidelines for protection
While patient is undergoing treatment for the
underlying medical condition and a preventive
regime has been instituted, one of the following
treatment modalities may be considered for protec-
tion of the remaining teeth/tooth tissue fromfurther
erosive damage and deterioration in the
appearance.
Dentine bonding agents, Seal and Protect (Dents-
ply, UK) and Optibond Solo (Kerr, UK), have been
shown to offer protection against erosion and
reduce the rate of tooth wear in vitro and in situ
70,
71
without adverse effect on pulpal circulation (in
rat studies).
72
This can be applied to protect
erosively exposed dentinal tissues.
Adhesively retained resins (composite resin or
glass ionomer cement) can be used in areas that
are not susceptible to high loads.
8
Porcelain veneers may be used to improve
appearance as well as provide protection against
further damage.
73
Recall and maintenance care
Failure to monitor the patient may result to relapse
of condition, therefore it is essential that a recall
care regime matched to the patients requirements
should be established, to check patient compliance,
monitor wear, reinforce advice, and for encourage-
ment to maintain changed behaviour.
Concluding remarks
Perhaps due to lack of devices for in vivo assessment
of the effect of preventive agents on eroded lesions,
there is shortage of in situ and in vivo studies on
erosion to support some of the in vitro ndings.
Hence, there is a need for development of a
diagnostic device, which can detect an early eroded
lesion and quantiably monitor the progress of
the lesion on a longitudinal basis. A remineralising
agent (mouthrinse or lozenge) specic for dental
erosion should be formulated for effective preven-
tion of erosion. Health education programmes
targeted towards reduction of the prevalence of
dental erosion and involving all healthcare personnel
should be developed. The qualities of acidic dietary
products should be modied-thereby reducing their
erosive potential.
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