Clinical Guidelines for Dental Erosion 2021 PDF

Clinical guidelines for dental erosion Diagnosis, prevention and management of dental erosion 2021  Clinical guidelines for dental erosion Contents Introduction3 Intended audience 4 Statement of confli...

Clinical guidelines for dental erosion Diagnosis, prevention and management of dental erosion 2021  Clinical guidelines for dental erosion Contents Introduction3 Intended audience 4 Statement of conflict of interest 4 Aims and objectives 4 Development and evidence base 4 Prevalence 5 Aetiology 7 Intrinsic acidic sources 8 Extrinsic acidic sources 10 Presentation and diagnosis  13 Management: preventative treatment 14 Patient information leaflets 14 Recording and monitoring erosion 14 Dietary analysis 15 Dietary counselling 16 GORD, vomiting and rumination 16 Oral hygiene, remineralisation and desensitisation 17 Other/novel preventative strategies 18 Management: restorative treatment 19 Primary dentition 19 Mixed dentition 19 Permanent dentition 20 References 24 Faculty of Dental Surgery 1 Clinical guidelines for dental erosion Lead Coordinator Elizabeth O’Sullivan Consultant in Paediatric Dentistry, City Health Care Partnership, Hull Contributors Ishpinder Toor Consultant in Restorative Dentistry, Guy’s and St Thomas’ NHS Foundation Trust, London Lucy Brown Consultant in Paediatric Dentistry, Harrogate District Foundation Trust Sophie Watkins Consultant in Restorative Dentistry, Guy’s and St Thomas’ NHS Foundation Trust, London 2 The Royal College of Surgeons of England  Clinical guidelines for dental erosion Introduction Toothwear is recognised as a major dental problem in both children and adults. The triad of erosion, attrition and abrasion has been known for many years, and the contribution of erosion to toothwear is increasing.1 Dental erosion is the irreversible softening and subsequent loss of dental hard tissue due to a chemical process of acid dissolution but not involving bacterial plaque acid, and not directly associated with mechanical or traumatic factors, or with dental caries. Attrition may be defined as direct tooth-to-tooth contact wear while external foreign agents moving across and contacting the tooth surface results in abrasion. Erosion usually coexists with attrition and/ or abrasion but one of these factors may be more significant than the others, making differential diagnosis difficult. Erosive wear is now deemed a common global phenomenon of developed countries,2 and its financial burden on patients and public health services is significant.3 More importantly, the morbidity associated with erosive wear may be high, and can include pain/sensitivity, dissatisfaction with aesthetics and reduced function. While the ultimate causative factors of dental erosion are non-bacterial acids, it is a multifactorial condition, and the progression of the lesions are driven by a complex interplay between nutritional and patient related factors. Owing to its progressive nature, preventative measures implemented (ideally, in the early stages of erosive wear) can be effective in reducing the need for dental intervention and symptoms experienced by patients. Operative measures will still be necessary for those with advanced erosion progression in order to eliminate pain, and to restore function and aesthetics. Additionally, interventive treatment may be warranted to preserve the structural integrity of the reduced and remaining tooth structure, and to protect against further tissue loss. This guideline aims to assist the dentist to diagnose, prevent and manage erosion in children, adolescents and adults. This may be complex, and can require interdisciplinary long-term management and liaison with medical colleagues. Faculty of Dental Surgery 3 Clinical guidelines for dental erosion Intended audience This guideline provides information for the whole dental team who are involved in the diagnosis, prevention and management of dental erosion. It would also be useful for other healthcare providers who give dietary advice to patients. It is intended that by using the guideline informed and evidence-based discussions can be carried out with patients. Statement of conflict of interest The Faculty of Dental Surgery is funded by its fellows and members, and no contributors or reviewers were paid for their work on this guideline. Aims and Objectives The aims and objectives of this guideline are to describe and explain the diagnosis, prevention and management of dental erosion in children and adults using evidenced based literature, so that clear information and discussions can be carried out with patients and carers. Development and evidence base This guideline was developed from existing guidelines by a small working group with members from the specialties of Paediatric Dentistry and Restorative Dentistry and the final draft was approved by each specialist societies clinical effectiveness group. At the beginning of development of the guideline the evidence base was established by each member carrying out a rapid review of the literature to optimise the use of the most current and relevant literature. The guideline development group employed a modified Delphi methodology (the guideline draft is circulated to the group, feedback is collated, before another draft is produced and circulated again for appraisal. In order for a recommendation to be included in the final guideline at least 90% of the working group were required to provide approval. Other stakeholders were then involved including the Dental Faculty RCS England Guideline Committee and the Delivering Better Oral Health Working Group. Final approval was sought from the British Society of Paediatric Dentistry and the British Society of Restorative Dentistry. 4 The Royal College of Surgeons of England  Clinical guidelines for dental erosion Prevalence Epidemiological studies over the past 20 years both in the UK and abroad have highlighted the prevalence for dental erosion.2,4,5 In recent reviews on the global prevalence of erosive wear, it has been deemed a common phenomenon of the general population of developed countries, with a mean prevalence in deciduous teeth of between 30% and 50%, and in permanent teeth of between 20% and 45%.2,6 Such wide variation in global prevalence rates is a reflection of the heterogeneity of erosive toothwear studies. This heterogeneity relates to factors such as differences in the toothwear indices used, sample size, study populations chosen and lack of standardisation in the quantification of dimensions of tissue loss. Prevalence data from cross-sectional UK studies indicate that dental erosion increases between different age cohorts of young people over time (Table 1).7–20 Prevalence of overall toothwear in dentate English adults increased from 66% to 76% between 1998 and 2008; moderate wear that has exposed a large area of dentine on any surface also increased from 11% (1998) to 15% (2009).21 This increase, however, is not uniform across age groups, with the greatest increases in adults seen in the younger age groups. A systematic review reportedthat the prevalence of toothwear in adults increases with age.22 While data could not indicate whether this increase simply reflected the aging process, it is probable that the increase in moderate toothwear is small in surveys conducted in England. Wear in younger adults is likely to be important clinically and is suggestive of more rapid toothwear attributable to factors other than age. Sex differences in the prevalence of toothwear are not clearly confirmed in the literature. Some studies have observed no association with sex, with others reporting a higher prevalence in one of the sexes. Overall, where a sex association has been found, the majority of studies favour an increased prevalence seen in male patients.2 Primary teeth have been shown to be more prone to erosive toothwear, which occurs more rapidly than in the permanent dentition,23 with the prevalence and severity of erosive toothwear increasing in the preschool population.24 Those patients who exhibit signs of erosive toothwear in the primary dentition have been shown to have an increased prevalence of erosion in the permanent dentition.25 Faculty of Dental Surgery 5 Clinical guidelines for dental erosion Table 1 Prevalence studies Author Year of Age Sample size % with dentine % with palatal / Teeth Surfaces publication* exposed occlusal / labial dentine exposed O’Brien7 1994 5 years Total 17,061 24% 24% U1” incisors 12/14 years 2% 2% U2” incisors Millward8 1994 4 years 178 48% All 1” teeth All Milosevic 9 1994 14 years 1,035 30% 8% 8% All 2” teeth Jones10 1995 3 years 135 17% U1” incisors Labial/palatal Hinds11 1995 1½–4½ years 1,496 8% U1” incisors Labial/palatal Smith 12 1996 65 years 1,007 26% with extensive All 2” teeth All toothwear Bartlett13 1998 11–14 years 210 2% All 2” teeth All Williams14 1999 14 years 525 11% 1% U2” incisors Labial/palatal Walker15 2000 4–6 years 363 19% U1” or 2” incisors Labial/palatal 7–10 years 500 18% First 1” or 2” Occlusal 11–14 years 518 3% molars 15–18 years 345 5% Al-Dlaigan16 2001 14 years 418 52% All 2” teeth All Bardsley 17 2004 14 years 2,351 53% 10% All 12 anterior Labial, incisal, teeth palatal/lingual First molars Occlusal Chadwick 18 2004 5 years Total 12,698 22% U1” incisors Labial/palata 12/15 years U2” incisors Labial/palata Dugmore19 2004 12 years 1,753 3% Incisors and Labial/palatal first molars Buccal/occlusal/ lingual Pitts2 2015 5 years 2,549 16%/4% U1” incisors Lingual/buccal 12 years 2,532 2%/– U2” incisors Lingual/buccal 12 years 2,532 1% First 2” molars Occlusal 15 years 2,418 4%/1% U2” incisors Lingual/buccal 15 year 2,418 3% First 2” molars Occlusal *not year survey conducted 6 The Royal College of Surgeons of England  Clinical guidelines for dental erosion Aetiology Dental erosion involves the softening of the tooth surface by acidic substances of intrinsic or extrinsic origin, or a combination of both.26 Repeated and prolonged contacts with acidic substances not only cause softening of the tooth surface but can also lead to overall loss of tooth structure.6 The softened tooth structure is further left susceptible to mechanical impact.27 Erosion, therefore, rarely has an isolated effect on toothwear but interacts with other wear mechanisms (abrasion, attrition) to potentiate their effect.28,29 The combination of chemical-mechanical tooth surface loss caused by the processes of dental erosion followed by abrasive and/or attritive wear is referred to as erosive toothwear.6,26 This term highlights the co-action between the three commonly recognised toothwear processes. As stated, the principal aetiological agents of erosive wear are intrinsic and extrinsic non-bacterial acids. Ideally, the source of the acidic substances should be identified prior to patient management. This is not always possible because of the difficulty in gaining an accurate and contemporaneous relevant history or because the patient may withhold important information regarding lifestyle or behaviour. Nevertheless, the identification and reduction of risk factors will improve the success of management. It is consequently important to question each patient about their medical history, medication, dietary content and habits, lifestyle and occupation. The dietary intake of acidic foodstuffs may be quite high in certain cases, and careful questioning on the intake of specific items of food and drink is necessary (Table 2). Dietary associations with erosion are present but weak. Future research may establish causal relationships and the influence of co-factors in the erosive process. In vitro studies have identified dietary factors with erosive potential but further research is needed to fully understand causal relationships and co-factors such as risky behaviours that increase the risk of erosion. Table 2 Dietary items with erosive potential Beverages Carbonated or fizzy drinks excluding ordinary unflavoured sparkling water Pure fruit juice, smoothies and cordials Certain alcoholic drinks (eg cider, white wine) Herbal teas Foods Fruits (especially citrus, grapes, sour apples) Sauces (eg ketchup, brown sauce) Snack foods (eg salt and vinegar crisps) Vinegar and pickled foods Faculty of Dental Surgery 7 Clinical guidelines for dental erosion In vitro studies show promise with respect to modification of drinks to reduce erosive potential.30,31 Continuing acid exposure not only results in a clinically detectable defect but also softens the tooth surface, making it more prone to mechanical impact. The primary causative factor is not always apparent; however, it is clear, for example, that while enamel is scarcely abraded by normal toothbrushing, it is rendered more susceptible to wear following an acid challenge.27 Intrinsic acidic sources The singular source of intrinsic acid related to dental erosion is gastric juice. Gastric acid may enter the mouth secondary to gastro-oesophageal reflux, vomiting or rumination and can lead to significant palatal erosion. Gastro-oesophageal reflux disease Reflux is the passive or effortless movement of regurgitated acid into the mouth and when this occurs regularly over a prolonged period, it is referred to as gastro-oesophageal reflux disease (GORD). It is this more persistent form of reflux that may lead to pathological dental erosion. GORD is considered relatively prevalent and in a 2014 systematic review, between 8.8% and 25.9% of adults in Europe were reported to be affected by this condition.32 The causes of GORD are summarised in Table 3. Table 3 Principal causes of gastro-oesophageal reflux Sphincter incompetence Oesophagitis Alcohol Hiatus hernia Pregnancy Diet (eg spicy/fatty foods) Drugs (eg diazepam) Neuromuscular (eg cerebral palsy) Increased gastric pressure Obesity Pregnancy Ascites Increased gastric volume After meals Obstruction Spasm 8 The Royal College of Surgeons of England  Clinical guidelines for dental erosion Signs and symptoms associated with reflux comprise heartburn, retrosternal discomfort, epigastric pain and hoarseness or asthma-like symptoms although symptoms are not reliable indicators of the presence or absence of GORD. Patients may be symptom free despite continuation of reflux. These patients are described as ‘silent refluxers’ and can remain undiagnosed. GORD is known to cause dental erosion and should always be considered a possible cause in the presence of indigestion, heartburn or epigastric pain.33,34 Extra-oesophageal symptoms (including dental erosion, chronic cough, asthma and laryngitis) have significant correlations with GORD.35 Furthermore, reflux disease patients with frequent respiratory symptoms appear to have a greater prevalence of dental erosion than those without reflux associated respiratory disorders.36 Clinicians should be mindful, however, that nearly 25% of adult patients presenting with extensive palatal erosion had pathological GORD diagnosed by standard criteria but did not have any symptoms of reflux.33 In silent reflux, dental erosion may therefore be the only clinical sign that reflux is occurring. Dental erosion in relation to GORD is less of a problem in children. This may be due to a shorter history of GORD or because refluxing is limited to the oesophagus.37 The exception is seen in neurologically impaired children, where significantly higher levels of gastric reflux are seen compared with healthy children, with over 70% of children with cerebral palsy having abnormal reflux activity.38–40 Vomiting Vomiting involves a host of physiological events, coordinated in the medulla, resulting in the forceful propulsion of stomach and upper intestinal contents towards the mouth. Vomiting may be spontaneous or self-induced and is often associated with an underlying medical condition. Spontaneous or self-induced vomiting needs to be persistent for dental erosion to occur, and the medical conditions associated most frequently with persistent vomiting include eating disorders, pregnancy, alcoholism and cyclic vomiting syndrome.41 Eating disorders can be divided into anorexia nervosa, bulimia nervosa, self-induced vomiting and eating disorders not otherwise specified.2 The prevalence of eating disorders in England in those aged 16 years and older is estimated at 7.8% and the disorder typically develops in younger females in their late teens to mid-twenties.42 Traditionally, it has been considered that teenage girls are particularly prone to abnormal eating behaviours; nevertheless, the number of affected males is felt to be underrepresented in the literature.43 Self-induced vomiting is a common feature of the eating disorders of anorexia and especially bulimia nervosa. Athletes including professional jockeys have also been reported to engage in this habit. Patients who self-induce vomiting have been shown to have higher risk of tooth erosion than peers who do not vomit.44 Eating disorders associated with vomiting are associated with an increased occurrence, severity and risk of dental erosion.² Interestingly, the frequency, duration and total number of self-induced vomiting episodes in those with eating disorders are not seen to be linearly associated with the severity or number of eroded teeth, indicating that other factors are at play. Spontaneous vomiting may occur frequently during the first trimester of pregnancy. Seen in children, cyclic vomiting syndrome is recognised to be linked with irritable bowel syndrome, motion sickness, migraine and epilepsy.41 Prolonged bouts (weeks) of vomiting can begin in preschool children, occur throughout child development and reduce in frequency by adulthood. The condition is therefore self-limiting. Faculty of Dental Surgery 9 Clinical guidelines for dental erosion Alcohol dependence may be associated with both regular vomiting and reflux, significantly increasing the risk for dental erosion. There is conflicting evidence in the literature regarding the relationship between alcohol dependence and erosive defects. However, a trend for both increased severity and prevalence of erosion is broadly seen in those with chronic alcoholism.45 Rumination The ability to relax the lower oesophageal sphincter, reflux gastric contents into the mouth and re-swallow is uncommon but has been reported.46 This naturally poses a risk for dental erosion. Extrinsic acidic sources There are multiple exogenous acids that have been discussed in relation to dental erosion. These can be categorised into those from dietary, pharmacological and environmental/lifestyle sources. Dietary extrinsic acids An acidic diet is widely associated with dental erosion, and careful questioning on the intake of specific items of food and drink is necessary (Table 2). A low pH and a high buffer capacity (the resistance of a dietary product to being neutralised by saliva) are deemed the major risk factors for erosive potential, with the calcium concentration in foods and drinks regarded as the major protective factor.26 It is important to consider all these factors together in understanding the erosive potential of foods and drinks. For instance, yoghurt has a low pH of 4 but a very high calcium concentration and therefore has a low erosive risk overall. Additionally, the consistency as well as the content of foods and drinks are important; a consistency that increases adherence to the tooth surface will clearly prolong the erosive challenge. While the erosive potential of specific dietary acids is important to consider, it is also necessary to review the overall pattern of consumption. Frequency of dietary acid intake is a primary risk factor for erosive toothwear progression.47,48 Four or more nutritional acidic intakes per day, in the presence of other risk factors (such as low buffering capacity of stimulated saliva and use of a hard bristled toothbrush), is associated with higher risk for the development and progression of erosion.49 Moreover, an increased frequency of dietary acids that are also consumed between meals represents a further increased risk for erosive toothwear.50 The above said, it should be noted that the relationship between dietary acids and erosion is not straightforward, with some who consume dietary acids developing erosive toothwear and others not.47 It is accepted that this a reflection of other co-factors being highly influential (eg salivary flow rates, buffering capacity and salivary composition). Future research is needed to fully understand causal relationships and the influence of co-factors in the erosive process. Drinks Carbonated soft drinks (including their sugar free counterparts) are considered to have a high erosive potential. Evidence linking dental erosion with soft drink consumption is available in the literature.51 Fruit juices, including smoothies, may also have high acidity and potential for dental erosion due to the fruit content and other additives (see Foods). For carbonated soft drinks, fruit juices and smoothies, the risk to children and adolescents is concerning given that consumption rates are high and increasing among this age group.6,52,53 Indeed, soft drinks have been reported to provide as much as a fifth of the added sugars in 10 The Royal College of Surgeons of England  Clinical guidelines for dental erosion the diet of 11–12-year-old children, and 42% of fruit drinks are consumed by children aged between 2 and 9 years.54 Drinks delivered from a feeding bottle, used as a comforter, may be particularly harmful to infants, with reported extreme dental destruction resulting from abuse of fruit juices.55 Preventative measures aimed at dietary extrinsic acids for children and young adults are therefore a vital strategy in reducing prevalence of erosive toothwear, especially as dietary patterns established in formative years can carry on into adulthood. The addition of fruit (particularly slices of lemons or limes) or fruit flavourings (eg cordials) to drinks has increased and it is safe to assume that any added fruit flavourings of this kind will render the beverage acidic.47 Fruit flavoured teas such as ginger and lemon, berry and rosehip are also considered acidic.47,56 There is some evidence that warming beverages may increase their erosive potential; this may be especially relevant to the consumption of fruit flavoured teas and hot cordials.57 Sports drinks are also considered to have a high erosive potential and are increasingly consumed owing to the promotion of active, healthy lifestyles. Some alcoholic drinks, such as dry wine, cider and alcopops, are also acidic.58–60 Alcohol consumption, as mentioned, is also linked with gastric reflux, and may consequently be both an intrinsic and extrinsic agent of erosion.61 As a general rule when simplifying the message for patients, most drinks that are not water, plain carbonated mineral water (sparkling water) or milk are acidic.47 Beverages with erosive potential are listed in Table 2. Part of the erosive potential of a given beverage is also the manner in which it is consumed. In a recent study, participants who admitted to constant sipping, swishing, swilling or holding the drinks in the mouth prior to swallowing had approximately ten times increased odds of developing erosive toothwear.50 This finding has been confirmed in other studies. Where advanced erosive toothwear is present in someone with seemingly limited acid exposure, the presence of a habit that increases the duration of contact between the acidic component and the tooth surface should be considered. Calcium and/or phosphate compounds have been added to beverages to test their effect in reducing the erosive potential. In vitro studies show promise with respect to modification of drinks to reduce erosive potential.30,31 Foods Fresh fruit and in particular citrus fruit62 have erosive potential, as do chillies and tomatoes.47 Foods pickled in vinegar and vinegars can be highly acidic; their consumption may be prevalent in certain international diets and are being increasingly promoted as part of a healthy diet. Less well known is the influence of covert acids in foodstuffs that have been associated with erosion in teenagers (eg brown sauce, crisps, ketchup and vinaigrette).63 Flavoured (acid-based, sugar containing) chewing gums are also considered to have potential for dental erosion. Foods with erosive potential are listed in Table 2. Lifestyle changes have undoubtedly increased the acidity content of modern diets. A greater emphasis on a healthy diet has resulted in an increase in fruit and vegetable consumption for Faculty of Dental Surgery 11 Clinical guidelines for dental erosion some individuals. National campaigns for healthy eating have also emphasised the importance of eating at least five portions of fresh fruit or vegetables per day, and the health benefits of consuming fruit and vegetables regularly should be encouraged as part of a balanced diet. (See the NHS Eatwell Guide – www.nhs.uk/live-well/eat-well/the-eatwell-guide.) More people are becoming vegetarian and this tends to be a more acidic diet. However, very few studies confirm a correlation with dental erosion and overall, the results are contraindicatory. Lacto-vegetarians were reported to have significant dental erosion although the study has not been repeated in order to confirm this association.64 Raw food diets, which include consuming only non-processed foods, have been shown in a small sample study to increase the risk of dental erosion versus consumption of a conventional diet.65 Given the importance of fruit and non-starch vegetables for general health, it is important that people are not advised to reduce their fruit consumption since as a society, we do not consume enough for health. Instead, only people for whom it is a clear identified risk factor should be advised to modify their diet to perhaps swap a citrus fruit for vegetables, banana or avocado between meals to ensure that they maintain a healthy diet and consume at least five a day. As with acidic beverages, it is not just the total exposure to acidic foods that appears to have increased in recent years. There have also been changes in dietary habits/patterns. The frequency of food intake is changing; greater numbers of snacks are being consumed and long periods of snacking are occurring, commonly known as ‘grazing’. In a multicultural society, there will be different habits and varieties of food not necessarily indigenous to the UK as well as different methods of food preparation. Little is known about these influences on dental erosion. Slaking palm with lime juice, betel nut chewing and crunching of chicken bones to savour the bone marrow have all been reported to increase the risk of toothwear and erosion.66 Although not usual among Western cultures, these habits will be common among people from other cultures who live in the Western world. Clinicians should be aware of these cultural differences and question patients about any habits that may increase the risk of wear. Pharmacological extrinsic acids A number of medications and dietary supplements (such as vitamin C, aspirin and some iron preparations) are acidic and potentially erosive if they are in the form of chewable tablets or effervescent drinks.26,67 It is unlikely, however, that these are in widespread use among children and adult population groups. Asthma medications have been speculated to increase dental erosion but the results are inconclusive.68,69 Many medications or medical treatments induce a dry mouth (eg antihistamines, anti- emetics, antidepressants, anti-Parkinson, diuretic medications, and head and neck targetted radiotherapy). The increased risk of erosion in these patients occurs because of the loss of salivary protective factors with reduced salivary flow. Furthermore, xerostomic patients may have a tendency to suck acidic sweets to alleviate their symptoms, which can further compound their risk of erosion. Some medications induce nausea and vomiting. The potential comorbidities of dry mouth and vomiting caused by some medications on dental erosion has not been investigated widely. Destruction of dental hard tissue can be found in drug dependent persons. Nevertheless, attritional toothwear is seen more commonly than erosive toothwear owing to drug induced muscle hyperactivity.70 12 The Royal College of Surgeons of England  Clinical guidelines for dental erosion Lifestyle/occupational extrinsic acids Active lifestyles and leisure trends can be associated with a greater risk of erosion,71,72 and in a systematic review of the oral health of elite athletes, prevalence values for dental erosion of between 36% and 85% were recorded.73 Professional athletes and swimmers are reported to be at increased risk of dental erosion due to exposure to sports drinks and swimming pool water. Well buffered, pH controlled chlorinated swimming pools, however, mitigate the risk of dental erosion and highly frequent swimming activities are therefore considered an uncommon risk factor for erosion.2 Work related exposure to acids in the form of liquids or vapours can result in dental erosion.74 Wine tasters, battery manufacture workers, and those working in galvanising and plating factories may be considered at increased risk for dental erosion. This is generally considered a rare cause of erosive toothwear and most industries have to adhere to occupational health legislations limiting exposure.26,71,74–76 The use of mood enhancing drugs such as ecstasy increases the risk of dental erosion/ toothwear.70,77–79 Presentation and diagnosis A diagnosis of erosive wear should be made as early as possible so that preventative strategies may be implemented quickly to limit further progression. Careful examination should consequently take place under good lighting with dry teeth to facilitate recognition of even the subtlest signs of dental erosion. In general, erosive toothwear is characterised by the loss of tooth surface morphology and contour. Few studies have investigated the site specificity of dental erosion but the literature indicates that the palatal and labial aspects of maxillary teeth and occlusal surfaces of the mandibular teeth are commonly affected.80 It is further reported that extrinsic acids contributing to dental erosion will predominantly affect the buccal cervical surfaces of the maxillary teeth and the occlusal surfaces of the mandibular posterior dentition. In cases of dental erosion caused by intrinsic acids, toothwear affects the palatal surfaces of the maxillary dentition, with protection of the lower anterior lingual surfaces by the tongue.81 On the occlusal surface, cusp tips may be cupped with flattening of occlusal contours and a less defined groove–fossa system may be observed. In advanced stages, the entire occlusal morphology may disappear with the presence of hollows, concavities and exposed areas of dentine. Concavities are typically wider than they are deep. Restorations may stand proud of the adjacent occlusal surface. Incisally, edges may become grooved or chipped and increased translucency may be seen, resulting in a bluish appearance. Exposure of dentine increases as erosion progresses. On smooth surfaces, there is flattening of the entire surface. Loss of the perikymata and cingulum may also be noted. As enamel becomes thinner, chamfered ridges or ledges in enamel are visible and can be felt with a probe. A thin band of enamel at the gingival margin may be observed on the labial and palatal aspect of maxillary incisors. Teeth may appear darker as the enamel thins and the yellow dentine increasingly shines through/is exposed. On both occlusal and smooth surfaces, the enamel acquires a rounded and glossy, shiny characteristic. Faculty of Dental Surgery 13 Clinical guidelines for dental erosion A diagnosis of dental erosion is made more difficult because of the triad of toothwear mechanisms and their complex interplay. While it is accepted that more than one type of toothwear mechanism is often in existence, identifying the principal aetiology will favour successful management. Occlusal erosive toothwear can be distinguished from attritive lesions, which are typically sharp and flat with matching facets. Smooth surface erosive toothwear can be distinguished from abrasive lesions, which are often wedge shaped, located at the cervical margin with sharp edges at right angles to the enamel surface. An accurate history will also help to elucidate the principal aetiology of toothwear defects. Radiographically, occlusal surfaces may appear eroded with loss of enamel and dentine thickness. Patients complain of poor aesthetics once a significant volume of enamel and dentine becomes lost, resulting in shortened anterior teeth and/or dentinal exposure. This is the common complaint on presentation rather than sensitivity or any functional difficulty. Useful means of estimating the current activity of erosive wear include reports of dentine hypersensitivity and the absence of staining. These indicators suggest progression of erosive toothwear. Management: preventative treatment As dental erosion is progressive, preventative measures delivered when there are only early signs of erosive toothwear can be particularly effective in reducing the morbidity and dental intervention experienced by patients. The main objectives of prevention are to reduce modifiable factors (extrinsic acids), to appropriately manage non-modifiable factors (intrinsic acids), and to record and monitor the erosion. An ‘active monitoring’ philosophy is recommended, especially if there are no patient reported concerns regarding pain/sensitivity, function or aesthetics. Clinically, if this approach is to be adopted, it must also be ensured that the remaining tooth structure will remain favourable to maintaining a comfortable, functional and aesthetic dentition in the long term, and that further loss of structure would not preclude or complicate restoration if this becomes necessary. Patient information leaflets These are very useful and allow patients to consider risk factors, behaviours etc in their own time. Patient information leaflets are produced by some companies or they can be made ‘in house’. Recording and monitoring erosion Regular monitoring of dental erosion should be established on an individual basis and will help to ascertain whether there is arrest or progression of the pathology. Records can also provide information on the efficacy of the preventative measures implemented. 14 The Royal College of Surgeons of England  Clinical guidelines for dental erosion In children and adults, good quality study casts and photographs aid the monitoring of dental erosion. While photographs can be stored digitally, safe storage of study casts can be problematic unless scanning and digital models are available. In adults, a silicone putty impression of the worst affected area is more readily stored with the patient notes and may be a helpful tool to assess progression. At a subsequent recall appointment, the putty index is sectioned labiopalatally and placed over the teeth. Any gap between the putty index and the tooth surface indicates progress of the erosion/wear and possible poor compliance with lifestyle changes. In children, growth and dentoalveolar development will preclude accurate seating of a putty index at review. Many different clinical indices have been proposed and experts in the field have recommended the use of the Basic Erosive Wear Examination.82 As per the Basic Periodontal Examination, the mouth is divided into sextants and the most severely worn tooth is graded according to a grading system (0 = no erosion; 1 = initial loss of enamel tooth surface texture; 2 = distinct defect, hard tissue loss