Dental Erosion

• Dental erosion is a chemical process characterized by acid dissolution of dental hard tissue not involving acids of bacterial origin.

• Erosive demineralization can result in progressive, irreversible loss of tooth mineral substance, and may be caused by intrinsic (e.g., acid reflux and excessive vomiting) and/or extrinsic (e.g., dietary) factors.

• Frequent consumption of soft drinks, particularly carbonated sodas, is a primary risk factor for erosive tooth wear. Consumption of acidic snacks/sweets or natural acidic fruit juice may also increase risk for erosion.

• Diagnosis and management of dental erosion includes careful clinical examination and evaluation of the patient to identify common signs of erosion (e.g., loss of enamel texture, cupping or flattening on occlusal surfaces), predisposing factors for erosive tooth wear, and options to reduce probability of exposure to erosive (acidic) drinks, dietary sources and/or other acids of intrinsic or extrinsic origin.

Intrinsic Causes

Intrinsic erosion results from the introduction of gastric acids into the oral cavity at a frequency, duration and/or intensity that exceed the ability of the buffering capacity of saliva or other oral health measures to minimize an erosive challenge, usually several times a week for an extended period of time. Stomach acid may reach the oral cavity in cases of gastroesophageal reflux disease (GERD), a common condition in which gastric contents reflux back up into the esophagus and/or the mouth. Other erosive challenges from gastric acid occur from recurrent vomiting, such as occurs in bulimia nervosa, chronic alcoholism, and pregnancy, when it is referred to as hyperemesis gravidarum.

• Gastroesophageal reflux. Gastroesophageal reflux disease is considered a predisposing factor for dental erosion due to chronic regurgitation of gastric contents. Some systematic reviews report that severity of erosive tooth wear may be associated with the frequency and/or intensity of acid regurgitation. Occasional regurgitation of stomach acids following meals, especially after overeating, is considered normal for up to about one hour a day. However, in people with GERD, the passage of gastric acids into the oral cavity during sleep is especially damaging to the teeth, as salivation and swallowing are reduced, and, in a supine position, the lower molars can be bathed in the acids.

• Bulimia. Bulimia nervosa is a serious eating disorder that is characterized by selfinduced vomiting as a means to maintain a desired weight. It is a relatively common disorder among women in Western industrialized nations, with a prevalence of approximately 5% in 18-35 year-old females. Among individuals with bulimia, the prevalence of erosion has been reported to be over 90%. Individuals with bulimia or other eating disorders are commonly found to have poor oral health, with one systematic review finding that patients with eating disorders and/or self-induced vomiting had five to seven times higher risk of dental erosion.

• Because patients with bulimia are generally of average weight, dentists are often the first to recognize the condition by the characteristic erosion of the lingual-palatal aspect of the anterior maxillary teeth (i.e., perimolysis or perimylolysis, see photos below),4 caused by the forceful expulsion of stomach acids onto the front teeth during vomiting.

• Pregnancy. Although dental erosion is rare in pregnancy, it has been reported in women who experience hyperemesis gravidarum, where the nausea and vomiting may be experienced over a longer period of time and may be more severe.

• Extrinsic Causes Erosion due to extrinsic factors may arise from a combination of dietary, lifestyle, environmental or occupational factors that expose teeth to acids in beverages or inorganic acid vapors in the environment.

• Beverages. A growing body of evidence suggests that the primary predisposing factor for extrinsic dental erosion is frequent consumption of soft drinks, sports drinks and fruit juices with low pH values (2.0-3.5). Any beverage with a low pH can increase risk for erosion

• Lifestyle. More frequent consumption of highly acidic fruit and sport drinks, in combination with decreased salivary flow and dehydration from athletic or strenuous activity, may increase erosion risk. Intense workouts may also increase the possibility of gastroesophageal reflux. Although there is some evidence that a vegetarian diet and excessive use of vinegar-based dressings may lead to increased erosion, a critical analysis of this topic noted that the evidence on erosivity of vegetarian diets has significant limitations and is relatively weak in overall quality.

• Diagnosis, Prevention and Management

• Erosive tooth wear may be diagnosed by integrating a review of findings from a detailed health history, assessment of relevant risk factors, and a comprehensive clinical examination. The process of erosive tooth wear begins with initial softening of the enamel surface with subsequent and/or progressive loss of volume, with a softened layer (i.e., less surface hardness) remaining at the mineralized tooth surface. Individuals with erosion may also present with dentition that has loss of enamel texture and/or a silky, glossy or “melted” appearance, with cupped, flattened or smoothed occlusal surfaces (or without the sound morphology of natural dentition).

• A detailed health history-taking process can help identify high-risk conditions (e.g., GERD, bulimia) or underlying causes that can elevate risk of exposure to acid erosive challenges, primarily acids of intrinsic (gastric) or extrinsic (dietary) origin. In the oral examination, the dentist may observe common signs of erosive tooth wear, such as shallow defects (typically on smooth surfaces) and cupping or flattening on occlusal surfaces .Additional signs of progressive erosive tooth wear may include dentin hypersensitivity and/or erosive lesions with absence of staining.Early diagnosis of dental erosion can be challenging because patients often present without clear or clinically evident symptoms.

• Since dental erosion results in progressive and irreversible loss of mineralized tooth substance, the primary focus of erosion intervention is prevention and reduction, followed by management. Clinical management typically includes lifestyle and dietary changes, and, if necessary, restorative treatment to halt progression of erosive lesions.

• Some studies have found that milk and yogurt products (presumably unsweetened) may have a protective effect against erosion hypothesized to be due to their calcium and phosphate content. While calcium supplemented to acidic beverages, and other calcium-enriched products, have been suggested as protective alternatives to soft and sports drinks, the efficacy of this strategy has not been thoroughly investigated. Fluoride may contribute to remineralization of enamel,but others have advised that fluoride’s “ability to prevent erosion cannot be presumed.

• More recently, however, several in situ studies suggest that fluoride treatments are effective in protecting dental enamel from the effects of erosion, although efficacy varies according to compound or preparation, and further research is needed.

• Patient Information

• Avoid dietary acids between meals, reduce intake of acidic beverages and eliminate behaviors that increase acidic (erosive) challenges to the dentition, particularly swishing or straining the liquid between the teeth, or holding the liquid in the mouth.

• Drinking with a straw positioned behind the front teeth can minimize bathing the teeth.

• Drink water while eating, or rinse the mouth with water after consuming acidic drinks, candies, or foods. o After vomiting, rinse the mouth with water, a sodium bicarbonate rinse, or milk.

• Saliva helps buffer and remove acids; chewing gum may help protect teeth from erosion by promoting salivary flow.

• Drink milk along with acidic meals or beverages, which contributes to remineralization and helps neutralize acids.

• Rinse with water rather than brushing teeth immediately after consuming acidic beverages. o Brush teeth using a soft-bristle brush and fluoride toothpaste. Dental abrasion (physical loss of mineralized tooth substance from objects other than teeth) may potentially occur in rare cases of excessive or aggressive toothbrushing. However, normal toothbrushing practices using a soft-bristle brush and low-abrasion, fluoridecontaining toothpaste are considered unlikely to cause erosive wear of enamel.

If you have any questions, please call us at 212-274 8338 or Book Online for a regular check-up at Empower Your Smile.