How to Manage Tooth Erosion PDF - 2021

FEATURE How to manage tooth erosion Dental hygienist Yana Mooney1 explains the features and causes of tooth erosion and discusses preventative care for ‘at risk’ patients. T ooth erosion is a type of toot...

FEATURE How to manage tooth erosion Dental hygienist Yana Mooney1 explains the features and causes of tooth erosion and discusses preventative care for ‘at risk’ patients. T ooth erosion is a type of tooth of tooth erosion is the first step in the dental soft tissues, such as the soft palate and back wear resulting in irreversible hygienist and therapist’s (DHT’s) management of the throat, are reddened and sore. Acid tooth surface loss. It is caused of the condition. In theory, acid erosion may be generated extrinsically eg: through an by the chronic exposure of can affect any tooth surface. The problems acidic diet where commonly buccal and labial dental hard tissue to acid, not observed can include: areas are affected. involving bacterial plaque. Tooth sensitivity Epidemiological studies have highlighted Poor dental aesthetics caused by enamel The chemistry of acid erosion the increasing prevalence of tooth erosion wear The dental hard tissue is made up of especially among the young.1 Modern diets, Dentine exposure, creating a dark tooth inorganic calcium hydroxyapatite crystal featuring the frequent consumption of colour Ca10(PO4)6(OH)2, which becomes weakened smoothies2 and energy drinks3 are leading to Chipping of incisal edges caused by during an acid attack. Calcium is released earlier signs of tooth erosion in younger age attrition (tooth to tooth wear) from the crystal structure – and substituted groups. Possible abrasion after heavy-moderate by relatively weakly attached minerals: Learning to recognise the physical features tooth brushing on a weakened tooth sodium, magnesium, phosphate (PO4) and/or surface. carbonate (CO3), and therefore the reformed hydroxyapatite crystal is more susceptible to The tooth surface is altered so the enamel acid dissolution,4 creating a weaker softened Author information appears thinner and tooth morphology may enamel structure which is vulnerable to 1 Yana qualified in July 2011 from be lost. The tooth surface may appear thin, physical wear. Eastman Dental Hospital School of smooth, shiny and more yellow in colour. ©Pikovit44/iStock/Getty Images Plus Hygiene with a Diploma in Dental Incisal edges become grooved with discrete Medical history Hygiene awarded by The Royal areas of exposed dentine and occlusal cusps On identifying a patient with the signs of College of Surgeons, England. She may become dimpled. tooth erosion, careful questioning is required is currently a self-employed dental The acid causing tooth erosion is generated to discover the potential risk factors. hygienist at the London Lingual either intrinsically ie: stomach acid entering Taking a medical history may reveal the Orthodontic Clinic. the mouth where commonly palatal, upper patient has a condition such as ‘Gastro- incisal and lower molar occlusal tooth oesophageal reflux disease’ (GORD) where surfaces are affected. DHTs may also notice stomach acid leaks via the oesophagus and www.nature.com/BDJTeam BDJ Team 7 © The Author(s), under exclusive licence to British Dental Association 2021 FEATURE into the mouth, eg hiatus hernia. Research Diet increases the risk of further tooth erosion shows that one third of adults in the West are If a medical history is inconclusive in Use a straw when drinking carbonated affected by GORD every few days.5 Remember determining the cause of tooth erosion then drinks, rather than sipping the liquid, to patients may be unaware they have a a diet analysis is necessary. Extrinsic acids minimise contact on the teeth and avoid condition like GORD and may describe an are acids introduced to the teeth generally holding/swilling the acidic carbonated unpleasant sour taste in their mouth, possible through diet. In addition to smoothies and liquid in the mouth heartburn or chest pains – in this case DHTs energy drinks, carbonated drinks, wines Avoid drinking acidic drinks at night time may recommend a GP appointment to and fruit juices can also cause tooth erosion. as saliva flow is reduced and acid contact eliminate any undiagnosed gastric problems. The patient should be asked to carry out a may be most damaging to teeth If the DHT suspects that the eroded teeth four-day diary (including a Saturday and Check the content of sports drinks and may be a result of an eating disorder, it is Sunday – as diet tends to alter slightly over opt for those with healthy additives like important that questions are asked gently, eg: the weekend) recording all the food and drink calcium, phosphate and fluoride – or better Are you aware of any acid reflux occurring they consume. The recordings should include still drink water or milk in the past, where stomach acid may have breakfast, lunch and dinner with snacks and Avoid diet drinks – they can be more entered your mouth? Patients with an eating drinks in between meals, remembering details erosive. disorder may have a history of bulimia or like the type of tea drunk, if sugar is added, if anorexia where self-induced vomiting has it’s a diet food and any sauces. Stimulating saliva flow occurred. It shouldn’t be assumed that only Analysis of the diet diary should be carried Saliva has a natural buffering capacity. thin looking patients may be anorexic or out by the DHT and advice given to the It contains bicarbonates and urea which bulimic. An adult patient’s teeth may show patient to help avoid potential erosive food neutralise acid in the mouth returning oral evidence of acid reflux but this may have and drinks. pH to a safe pH of 5.5. Patients should be occurred as a result of purging food as a The DHT should also consider the patient’s encouraged to chew sugar-free gum after teenager. If the patient reacts awkwardly to social history. For example: the patient who eating or drinking. Chewing gum stimulates your question, it’s probably best to move on has an active lifestyle, enjoys working out saliva which can neutralise the action of from the subject, recording details in the at the gym, athletics or body-building may acidic foods and drinks on the teeth and can clinical notes. At this point, it may be worth rely on certain foods and drinks to improve be a useful adjunct in the prevention of tooth suggesting your patient carry out a diet diary their training and performance. The DHT erosion. Studies have shown chewing sugar to help identify the cause of tooth erosion. should have an awareness of which food free gum stimulates saliva production for up to two hours, and increases in both flow rate and pH is seen after chewing for 20 minutes.8,9 ‘DHTs should always cross check Oral hygiene instruction Oral hygiene instructions should be tailored medications taken by patients to find to a patient who is at risk of tooth erosion. The patient should be advised not to use a hard bristled toothbrush and to avoid a heavy out if there are any side effects that scrubbing technique as this would encourage further wear on an already weakened tooth may contribute to tooth erosion, eg: surface. Also consider if the dentine layer is exposed, as this layer has a lower inorganic mineral content, and toothbrush abrasion nausea, vomiting and/or dry mouth.’ would be more likely. It would be best for patients to use a medium to soft manual toothbrush with a gentle brushing (modified bass technique) motion. Some patients may DHTs should always cross check and drinks may be harmful and advise a prefer to use an electric toothbrush to avoid medications taken by patients to find out if possible alternative. A study carried out to a scrubbing technique by placing the rotating they are any side effects that may contribute to determine the dental hazards associated with or vibrating head on the tooth surface still for tooth erosion, eg: nausea, vomiting and/or dry eight different sports drinks found that while two seconds. An electric toothbrush can help mouth. For example, chemotherapy can cause sports drinks have erosive potential drinks, to limit the application of excessive force too vomiting, painkillers contain codeine which those which contain higher concentrations as many have warning devices – like a flashing can cause sickness and nausea; meanwhile, of calcium, phosphate and fluoride will red light (Oral B Professional Range) – or antidepressants are known to reduce saliva reduce this erosive potential.3 Diluting orange bleep/buzz sound (Philips Sonicare Flexcare) flow causing dry mouth and so the natural juice with water may be an option as well as - to alert patients when they are pushing too buffering capacity of saliva is reduced and the choosing a drink that’s fortified with Calcium hard. acid neutralisation potential lost. Effervescing and Vitamin D. Patients should also be advised not to medicines like Vitamin C and dispersible In summary, preventative advice might brush teeth immediately after consuming aspirin can also be acidic. Pregnancy may include: acidic foods or drinks or after an episode cause regular nausea and spontaneous Avoid grazing on acidic foods or acidic of acid reflux as the erosive action may be vomiting contributing to acid wear.6,7 drinks in between meals as the pH of the magnified by rubbing the acid on the tooth mouth is being frequently lowered which softened dental surface. 8 BDJ Team www.nature.com/BDJTeam © The Author(s), under exclusive licence to British Dental Association 2021  FEATURE Fluoride advice offered a superior anti-erosion effect than 2. O’Sullivan E, Barry S, Milosevic A, Brock A recent review of literature has shown that other commercially available fluoride G. Diagnosis, prevention and management fluoride can strengthen teeth against acid toothpastes.13 Patients who are considered of dental erosion. 2013. Available at: https:// erosion. Receiving daily fluoride through at high risk of erosion or exhibit dentine www.rcseng.ac.uk/-/media/files/rcs/fds/ toothpaste and mouthrinse and/or high- exposure may benefit from a toothpaste that is publications/dental-erosion-2013.pdf concentration fluoride toothpaste is the best less abrasive and delivers fluoride. (accessed October 2021). method for protecting the teeth against acid A 2012 study on the effect of Sodium 3. Milosevic A. Sports drinks hazard to teeth. erosion.10 This is because the fluoride mineral Fluoride (NaF), Stannous Fluoride (SnF2) and Br J Sports Med 1997; 31: 28–30. incorporates into the dental hard tissue to Titanium Tetrafluoride (TiT4) toothpaste on 4. Featherstone J D B, Lussi A. form a stronger, more acid resistant Fluoro- enamel and dentine erosion-abrasion found Understanding the chemistry of dental hydroxyapatite crystal structure and is less that toothpaste containing (SnF2) (1100 ppm erosion. Monogr Oral Sci 2006; 20: 66–76. susceptible to acid dissolution during acid F-)/(NaF) (350 ppm F-) combined eg Oral 5. Barlett D W, Evans D F, Anggiansah A, challenges than the Calcium-hydroxyapatite B Pro Expert toothpaste and (TiF4) (1100 Smith B G N. A study of the association crystal.11 ppm F-)/NaF (350 ppm F-) combined was the between gastro-oesophageal reflux and Patients therefore should be encouraged to most effective in reducing enamel wear post palatal erosion. Br Dent J 1996; 181: brush with a fluoride toothpaste twice a day acid exposure. The study also revealed that 125–132. and to spit out the fluoride toothpaste and brushing with water alone was less abrasive 6. Grace E G, Sarlani E, Kaplan S. Tooth not rinse with water after brushing to allow and showed less enamel wear than brushing erosion causing chewing aspirin. J Am a fluoride residue to remain on the tooth with a non-fluoride toothpaste.14 Dent Assoc 2004; 135: 911–914. surface. Regular use of a fluoride mouthrinse 7. Giunta J L. Dental erosion resulting from during the day, after lunch for example, can Professional remineralising products chewable vitamin C tablets. J Am Dent help remineralise the tooth surface. It may As well as the use of fluorides, there is Assoc 1983; 107: 253–256. also be appropriate to encourage patients at ongoing research into new agents such 8. Dawes C, Kubieniec K. The effects of risk of tooth erosion to use toothpaste with a as GC Tooth Mousse CPP-ACP: Caesin prolonged gum chewing on salivary flow higher concentration of fluoride eg: Colgate Phosphopeptide-Amorphous Calcium rate and composition. Arch Oral Biol 2004; Duraphat 2800 ppm, and Duraphat 5000 Phosphate and GC Tooth Mousse Plus 49: 699–705. ppm. - Caesin Phosphopeptide-Amorphous 9. Pollard K E, Higgins F, Orchardson DHTs may wish to apply a fluoride varnish Calcium Phosphate with fluoride and how R. Salivary flow rate and pH during (high concentration fluoride) to a tooth they can help remineralise erosive lesions. prolonged gum chewing in humans. J Oral surface which is at most risk of erosion. The A recent study illustrates how these agents Rehabil 2003; 30: 861–865. protective varnish film containing fluoride control acid erosion by supersaturating 10. Magalhães A C, Wiegand A, Rios D, will reduce direct contact between tooth the dental hydroxyapatite crystal with Buzalaf M A, Lussi A. Fluoride in dental surface and acid while delivering fluoride bio-available calcium and phosphate ions, erosion – A Review. Monogr Oral Sci 2011; to strengthen enamel and dentine surfaces. limiting demineralisation and promoting 22: 158–170. An in vitro study on the 24-hour effect of remineralisation.15 DHTs could consider 11. Hicks J, Garcia-Godoy F, Flatiz C. Duraphat (2.26% F) varnish on molar teeth advising patients to use GC Tooth Mousse Biological factors in dental caries enamel prior to submersion in a cola drink revealed as a daily alternative to toothpaste to help structure and the caries process in the that the fluoride varnish treatment increased remineralise erosive lesions. dynamic process of demineralization and enamel hardness and therefore limited enamel remineralization (part 2). J Clin Pediatr softening during the acid attack.12 Conclusion Dent 2004: 28: 119–124. As DHTs it is our duty of care to recognise 12. Sorvari R, Meurman J H, Alakuijala P, Which toothpaste? and help our patients prevent dental Frank R M. Effect of fluoride varnish and The wide choice of toothpastes on erosion. From the outset, it is essential that solution on enamel erosion in vitro. Caries supermarket shelves can be baffling for thorough dental records are taken, including Res 1994; 28: 227–232. consumers. It may be helpful if DHTs photographs and study models, so a historical 13. Barlow A P, Sufi F, Mason S C. Evaluation show patients how to read and recognise document and visual record of the teeth is of different fluoridated dentifrice ingredients in toothpaste that can prevent available and tooth changes may be monitored formulations using an in situ erosion tooth erosion. over time. If DHTs observe from records that remineralization model. J Clin Dent 2009; For example: Toothpaste should tooth wear is progressing, it may be necessary 20: 192–198. contain 1450 parts per million fluoride as to consult with a dentist colleague regarding 14. Comar L P, Gomes M F, Ito N, Salomão P standard and may be presented as ‘Sodium who will help decide on the best intervention A, Grizzo L T, Magalhães A C. The effect Fluoride (NaF) (1450 ppm F-)’ or ‘Sodium for your patient. Discussions should be had of NaF, SnF(2) and TiF(4) toothpastes Monofluorophosphate 1.1% w/w (1450ppm on a suitable in-house protocol on how to on bovine enamel and dentine erosion F-)’. manage, prevent and treat dental erosion. - abrasion in vitro. Int J Dent 2012; doi: In 2009, an evaluation of different 10.1155/2012/134350. fluoridated toothpastes found that in situ all References 15. Somani R, Jaidka S, Singh D J, Arora V. toothpastes containing sodium fluoride had 1. Nunn J H, Gordon P H, Morris A J, Pine Remineralizing potential of various agents the ability to re-harden enamel previously C M, Walker A. Dental erosion – changing on dental erosion. J Oral Biol Craniofac Res softened with an erosive challenge and that prevalence? A review of British national 2014; 4: 104–108. in particular Sensodyne Pronamel and children’s surveys. Int J Paediatr Dent 2003; Sensodyne Pronamel Gentle Whitening 13: 98–105. https://doi.org/10.1038/s41407-021-0742-5 www.nature.com/BDJTeam BDJ Team 9 © The Author(s), under exclusive licence to British Dental Association 2021