Managing Dental Erosion PDF

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FEATURE N G G I NA L A A M ENT D E R O S I O N enton, By Carolyn R nist and dental hygie dergraduate therapist, un nt dental stude ©iStockphoto/Thinkstock Dental erosion is on the increase same as dental caries where there is dissolution There is common awareness within the dental profession that dental erosion is of hydroxyapatite crystals; however, the clinical on the increase. What is causing this increase and what can be done to prevent manifestation is fundamentally different this irreversible destruction? This article will explore the aetiology, risk factors, diagnosis because the erosive process does not contain and clinical features of dental erosion. It will also suggest practical tools for passive and bacteria. Instead erosion results from exposure active roles in the prevention and management of dental erosion. to non-bacterial acids of either an extrinsic or intrinsic origin.3 It is caused by sustained Introduction conducive to remineralisation, whereas erosion direct contact between tooth surfaces and acid In the last decade tooth erosion has drawn is a surface-softening lesion that is susceptible substances, essentially, whatever causes the increasing attention as a risk factor for enamel to wear and resistant to remineralisation by oral pH to drop below the critical point of 5.5. wear. There is evidence that its prevalence is conventional therapies. Clearance of the acids is often down to the growing steadily and there has been a gradual salivary flow rate and the buffering capacity. realisation that the younger population are Aetiology being increasingly affected.1 Erosion is usually multifactorial and often Risk factors Dental erosion is the irreversible loss of co-exists with other non-carious tooth surface There are three different risk factors: intrinsic hard dental tissue due to a chemical process loss such as abrasion, attrition and abfraction. sources, extrinsic sources and predisposing of acid dissolution but not involving bacterial Over time the interaction of all these factors factors. plaque acid, and not directly associated with may lead to the progressive loss of tooth tissue 1. Intrinsic acid sources are of gastric origin mechanical or traumatic factors, or with dental and there are often overlapping factors that and enter the mouth from the stomach. caries.2 Although similar, the caries process may play a role. Examples of sources are listed in Table 1. begins as a sub-surface enamel lesion that is The chemical process of dental erosion is the Intrinsic acid is heavily associated with www.nature.com/BDJTeam BDJ Team 18 © 2014 Macmillan Publishers Limited. All rights reserved FEATURE significant palatal wear of the maxillary teeth. A thorough medical/dental history Table 1 Examples of extrinsic and intrinsic acid sources can establish any underlying issues the patient may have. Acid Type Risk factor Example 2. Extrinsic acid sources are substances taken into the oral cavity. There has been much Extrinsic scientific research into the habits of dietary practices especially with the emphasis on Fruit healthy food and drink. A trend towards an increased number of eating occasions Fruit juice has been observed, and if the increased Sports/energy drinks Dietary number of occasions are accompanied by Fruit smoothies the inclusion of acidic foods or drinks at Carbonated beverages (diet) each occasion, then this could heighten the risk for erosive damage.4,5 With a healthy Wine lifestyle comes frequent exercise which can also potentially lead to frequent intake of Wine taster Occupational acidic sports beverages. Certain occupations Metal sheet worker and lifestyle choices can also make patients more vulnerable.6,7 Swimmer 3. Salivary flow and buffering capacity can Environmental Athlete have a big impact on clearance of acidic substances. Saliva contains bicarbonate Vitamin C and urea and rapidly neutralises the acid Medication remnants and returns the pH to normal.8 Aspirin If a person has low saliva rates and poor buffering capacity they are much more Ecstasy Lifestyle likely to suffer with erosion. Frothing/swishing drinks Benefits of chewing Intrinsic Whether the acid attack is caused by extrinsic, intrinsic or predisposing factors, the pH of Antihistamines saliva can be modified by chewing sugar free Medication Antidepressants gum for 20 minutes after acid exposure. The Antipsychotics increased levels of bicarbonate and calcium ions assist in a more rapid remineralisation of the tooth surface.9 Many studies show that GORD (reflux) if saliva is stimulated through chewing gum Illness Bulimia plaque acid is neutralised more quickly than if Frequent vomiting (pregnancy) gum is not used. Also, chewing sugar-free gum is shown to help remove up to 95% of residual Lifestyle Rumination food debris within just a few minutes.10,11 Diagnosis imperative to recognise the signs of erosion to 2. Ascertain underlying diseases or Accurate diagnosis of erosion begins with facilitate early intervention before significant medications associated with the presence assessment of risk factors and relevant medical/ hard tissue is lost. Once suspicion is raised, it is of intrinsic acids. It may be necessary to dental histories and visual examination. If essential to record accurately the severity and consult with the patient’s doctor it is detected in the early stages appropriate extent in order to establish a baseline for future 3. Monitor progression with tooth wear steps can be taken to halt its progression. observations. indices, photos, study models, silicone Erosion often presents on the palatal surface impressions and splints15 of the maxillary teeth, and the occlusal surface Passive management 4. Provide personalised dietary counselling, of the mandibular first molars. It can also The main thrust of prevention is to change or refer patient to a dietitian where be seen on the buccal surfaces of maxillary lifestyle and to record and monitor the applicable. After completing a diet diary and mandibular canines and premolars, and progression. If the patients have no and personalised consultation, you may occlusally on the maxillary and mandibular complaints regarding pain and sensitivity recommend: canines and molars.12 Early signs include a ‘watch and wait’ principle should be a. Reducing the frequency and smooth flat facets on buccal or palatal employed.14 There are several steps to follow consumption of acidic foods and drinks surfaces, and shallow, localised dimpling on before active management approaches should where appropriate the occlusal surfaces.13 Since hard tissue loss is be undertaken: b. Sugar-free alternatives where applicable irreversible, worn dentition is a great challenge 1. Inform the patient of the problem and its c. Avoid frothing and swishing especially for clinicians and their patients, making it causes, and provide appropriate literature with carbonated beverages 19 BDJ Team www.nature.com/BDJTeam © 2014 Macmillan Publishers Limited. All rights reserved  FEATURE d. Chew sugar-free gum for 20 minutes position is essential prior to treatment to diet advice, increasing salivary flow to after the consumption of acidic foods, assess the working space; possible procedures neutralise the acids by chewing sugar-free gum, explaining the benefits outlined above could be: and minimising toothbrush abrasion with e. Do not brush for at least an hour after 1. A dahl appliance may be required if there is personalised oral health education. the consumption of acidic foods palatal erosion of the upper anterior teeth f. Avoid occupational exposure with with no inter-occlusal space, as it will create 1. Lussi A, Schlueter N, Rakhmatullina E, Ganss C. mouth guards, splints or neutralising an open bite and allow relative extrusion Dental erosion – an overview with emphasis on chemical and histopathological aspects. Caries Res agents of the posterior teeth to later provide 2011; 45 Suppl l: 2-12. g. Use a high fluoride, low abrasive composite resin restorations17 2. Ren Y F. Dental erosion: etiology, diagnosis and toothpaste, and a soft-medium bristled 2. In generalised erosion evaluation of the prevention. J Dent 2011; 14: 1-6. brush freeway space may lead to restoration by 3. Kelleher M, Bishop K. Tooth surface loss: an 5. Apply fluoride varnish to susceptible way of conventional crown work.18 overview. Br Dent J 2009; 186: 61-66. surfaces to provide a protective film and 4. Dugmore C R, Rock W P. A multifactorial analysis reduce direct contact between tooth Conclusion of factors associated with dental erosion. Br Dent J surfaces and acid.1 Prolonged exposure from acids either intrinsic 2004; 196: 283-386. or extrinsic on the tooth surface will result in 5. Giunta J L. Dental erosion resulting from chewable Active management softening and dissolution of surface minerals. vitamin C tablets. J Am Dent Assoc 1983; 107: 253- 256. Invasive procedures should not commence If it is not diagnosed and treated early it may 6. Duxbury A J. Ecstasy – dental implications. Br Dent until a period of monitoring has taken place cause irreversible loss of hard dental tissue. J 1993; 175: 38-39. and the erosive progression has halted. Early intervention is key to effective prevention 7. Mandel L. Dental erosion due to wine consumption. Assessment of space in the inter-cuspal by reducing direct contact with acids through J Am Dent Assoc 2005; 136: 71-75. 8. Jaeggi T, Lussi A. Prevalence, incidence and distribution of erosion. Monogr Oral Sci 2006; 20: CPD QUESTIONS 44-65. 9. Fui Y, Li X, Ma H et al. Assessment of chewing Test yourself on this article by answering the questions below, and include reading this article in your record as one hour of non-verifiable (general) CPD. sugar-free gum for oral debris reduction: a randomised controlled crossover clinical trial. Am J The answers will be published in the November issue of BDJ Team. Dent 2012; 25: 118-122. 1. Dental erosion is: 5. Signs of erosion: 10. Wefel J S, Jensen M E, Hogan M et al. Effect A. due to eating a diet consisting of A. are usually in the form of jagged of sugar-free gum on human intra-oral course food deep cavities demineralisation and remineralisation. J Dent Res B. the irreversible loss of hard tissue due to B. most frequently occur on the labial surfaces 2003; 68: 214-263. alkaline foods and drinks of upper incisors 11. Dawes C, Dong C. The flow rate and electrolyte C. the irreversible loss of hard tissue due to a C. include smooth, flat facets on the buccal or composition of whole saliva elicited by the use of chemical process of acid dissolution palatal tooth surfaces sucrose containing and sugar free gums. Arch Oral D. caused by bacterial plaque D. may be detected early on the mesial and Biol 1995; 40: 699-675. distal surfaces of first molars 2. Which of the following describes the process 12. Correr G M, Alonson R C, Consani S, Puppin- of erosion? 6. In preventing erosion the main activity involves: Rontani, Ferracane J L. In vitro wear of primary A. it begins with bacteria which are A. early extraction of all teeth involved and permanent enamel. Simultaneous erosion and sub-surface in dental hard tissues B. changing the patient’s lifestyle, recording abrasion. Am J Dent 2007; 20: 394-399. B. it is a surface-softening lesion and monitoring progression 13. Smith B G N, Knight J K. An index for measuring C. it can be remineralised by C. recommending twice-daily salt the wear of teeth. Br Dent J 1984; 156: 435-438. conventional therapies water mouthwashes 14. Shaw L, Smith A J. Dental erosion – the problem D. it is not susceptible to wear D. eating as many healthy acidic fruits and some practical solutions. Br Dent J 1998; 186: as possible 115-118. 3. The aetiology of erosion is: 7. Which of the following is not a recommended 15. Hicks J, Garcia-Godoy F, Flaitz C. Biological factors A. caused by exposure to non-bacterial acids aspect of dietary counselling? in dental caries enamel structure and the caries B. mediated by the oral pH being above the critical point of 6.5 A. avoiding frothing and swishing of process in the dynamic process of demineralization C. unaffected by the salivary flow rate carbonated beverages and remineralization. J Clin Pediatr Dent 2005; 29: D. solely caused by extrinsic acids from foods B. brushing immediately after acid exposure 119-124. taken into the oral cavity C. using high fluoride toothpaste 16. Azzopardi A, Bartlett D W, Watson T F, Sherriff D. chewing sugar-free gum M. The surface effects of erosion and abrasion on 4. Chewing sugar-free gum for 20 minutes after dentine with and without a protective layer. Br Dent acid exposure: 8. Active treatment: J 2004; 196: 351-354. A. removes only 45% of residual food debris A. should only commence after a period 17. Redman C D, Hemmings K W, Good J A. The B. decreases levels of bicarbonate and of monitoring and the erosive progression had halted survival and clinical performance of resin-based calcium thereby lowering the pH of saliva B. is unlikely to include crown work as there is composite restorations used to treat localised C. neutralises plaque acid more slowly insufficient tooth tissue remaining anterior tooth wear. Br Dent J 2003; 194: 566-572. D. assists in a more rapid remineralisation of the tooth surface C. can start without regard to the 18. Hemmings K W, Darbar U R, Vaughan S. Tooth working space wear treated with direct composite restorations t D. may require composite resin build-up of the increased vertical dimensions: results at 30 months. anterior teeth to create further space in the J Prosthet Dent 2000; 83: 287-293. posterior quadrants bdjteam2014109 www.nature.com/BDJTeam BDJ Team 20 © 2014 Macmillan Publishers Limited. All rights reserved