Dental Erosion Possible Approaches

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  Dental erosion: possible approachesto prevention and control B.T. Amaechi a, *, S.M. Higham b a Cariology Unit, Department of Community Dentistry, University of Texas Health Science Centreat 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 apreventive programme for dental erosion. Data and sources . The data discussed are primarily based on published scientificstudiesandreviewsfromcasereports,clinicaltrials,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 dentalerosion were reviewed. Strategies to either prevent the occurrence or limit thedamage of dental erosion or protect the remaining tooth tissues from further erosivedestruction were reviewed and discussed. These includes: (A) measures to (1)enhance remineralisation and acid resistance of enamel surface softened by erosivechallenge, (2) reduce the erosive potential of acidic products, (3) enhance salivaryflow, (4) protect and restore erosively damaged tooth, and (5) provide mechanicalprotection against erosive challenge. (B) Health education geared towards (1)diminution of frequency of intake of dietary acids, and (2) change of habits andlifestyles that predispose teeth to erosion development. Conclusions . It may be easier to gain patients’ compliance with the advice thatimmediately following an acidic challenge, a remineralising agent, such as fluoridemouthrinses, fluoride tablets, fluoride lozenges or dairy milk, should be administeredto enhance rapid remineralisation of the softened tooth surface as well as serve as amouth refresher, or an alternative, a neutralising solution should be used. Effectivecounselling 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 toothwear, is the loss of dental hard tissue through eitherchemical etching and dissolution by acids of non-bacterial srcin or chelation. The occurrence of this Journal of Dentistry (2005)  33 , 243–$ - see front matter q 2004 Elsevier Ltd. All rights reserved.doi:10.1016/j.jdent.2004.10.014* Corresponding author. Tel.:  C 1 210 567 3200/3185;fax:  C 1 210 567 4587. E-mail address: (B.T. Amaechi).  condition was reported asearly asthe 19thcentury, 1 andsincethentheincidenceandprevalenceofdentalerosionisincreasinglybeingreported. 2 Thisisevidentfrom prevalence studies conducted in two differentpartsoftheworldwithinthelastdecadethatshowedthe percentage of individual affected by erosion(Table1)amongvariousagegroups. 3–7 Especiallywiththedeclineincariesrateinsomecountries,erosionisnow becoming a focus of increasing interest both inclinical dentistry and research. The management ofdental erosion is an area of clinical practice that isundoubtedly expanding. 8 The past two decades haveseen numerous investigations and reports on the prevalence, 2 the aetiology, 9 the pathogenesis andthe modifying factors 10–16 of dental erosion. It is nowtime for development of a preventive programme tocontrol the prevalence of this dental destructivedisorder. Therefore, the key elements required fordesigning and the achievement of an effectivepreventive programme are discussed and rec-ommended in this paper. These are discussed underthe following headings:1. Erosion predictors—conditions identified as topredispose teeth to the development of dentalerosion.2. Guidelines for prevention and control—rec-ommendations for preventing and controllingdental erosion.3. Guidelines for protection—recommendations forthe protection of remaining tooth tissues fromfurther damage and deterioration. Key elements of an effective preventiveprogramme Use of erosion predictors An important step towards prevention of dentalerosion should be the identification of thoseindividuals who are at risk of dental erosion.Evidence based on case reports, clinical trials,epidemiological, cohort, animal, in vitro and invivo studies have described acids that could causedental erosion as srcinating from gastric, dietary orenvironmental sources. Based on this fact, certainfactors have been identified as the predictors ofsusceptibility to dental erosion. Medical conditions Chronicvomiting in eating disorders such asanorexiaand bulimia nervosa, passive regurgitation in gastro-oesophageal reflux disease (GORD) and eitherpassive regurgitation or chronic vomiting in chronicalcoholism and binge drinking, 17,18 have all beenassociated with repeated direct contact of teethwith gastric contents, the pH of which can be as lowas 1, resulting to acidic dissolution of dental hardtissues. Misuse of acidic dietary products Frequent and prolonged ingestion of acidic fruits,fruit juices and acidic beverages has been reportedas causing dental erosion. 9,12 This is observed incases such as habitual intake, dieting with citrusfruits and fruit juices, drinking during strenuoussporting activities, bed-time use in reservoir feederor continuous use in baby bottle feeding as acomforter. Bed-time baby bottle feeding and GORDare likely to be more destructive due to decrease insalivary flow during sleep. Furthermore, deciduousteeth in vitro have been shown to be one and halftimes more susceptible to erosion than permanentteeth. 12 These practices would lower the pH of theoral fluids for a prolonged period, thus exposing theteeth to prolonged periods of acidic challenge withconsequent etching and dissolution. It has beenestablished that the rate of consumption of purefruit juices and acidic beverages is increasing 19 as aconsequence of their ease of availability and lack ofexpense. Use of acidic medicaments Case reports have revealed that acidic medica-ments prescribed frequently for long periods oftime, predispose teeth to dental erosion. 9,20 Medicaments such as acetylsalicylic acid, ascorbicacid, liquid hydrochloric acid, iron tonics, acidicsaliva stimulants/substitutes and products withcalcium chelating properties have high erosivepotentials. Occupation The occupation of a patient may give a clue as tohis/her susceptibility to dental erosion. Industrialprocessing procedures exposing workers to acidic Table 1  Summary of prevalence studies of dentalerosion.Age (years) % affected Evidence1–4 20 UK ToddlersSurvey 3 4–5 38 Millward et al. 4 5–6 52 UK Child DentalHealth Survey 5 11 25 UK Child DentalHealth Survey 5 11–14 57 Bartlett et al. 6 26–30 30 Lussi et al. 7 45–50 42.6 Lussi et al. 7 B.T. Amaechi, S.M. Higham244  fumes or aerosols as in the case with battery andfertiliser factories, professional swimming in impro-perly pH-regulated swimming pools and professionalwine tasting, have all been linked to dental erosionthrough several case reports. 9,21–23 Use of illegal drugs Addictive use of certain illegal drugs such as cocaineand ecstasy is associated with excessive consump-tion of acidic beverages, due to the side-effects ofdehydration and hyposalivation, 24 thus predisposingthe user to the risk of dental erosion. Lactovegetarians Dental erosion has been reported to be commonamong lactovegetarians due to an associated hypo-salivationandhighconsumptionoflow-pHfoodstuffscombined with the abrasive effect of the coarsefresh food. 25 Excessive oral hygiene procedure Frequent tooth brushing with abrasive dentifrice aspracticed by some health/aesthetic-conscious indi-viduals may render the tooth surface more suscep-tible to erosion due to removal of the moreprotective highly mineralised outer layer of enamelsurface 26 and reduction of the thickness of theacquired salivary pellicle, which would adverselyaffects its established protective role against dentalerosion. 11 Guidelines for prevention and control The above erosion predictors highlight the fact thatthe elimination of the causative factor may bedifficult since the individuals who are susceptible todental erosion might have either psychological orprofessional inclinations to the factors predisposingthem to the disorder. This would obviously posedifficulty in obtaining full compliance with preven-tive advice, even when the causative factor isidentified. However, the following recommen-dations, if implemented in a preventive programme,might prevent occurrence, limit the damage, modifythe habit or protect the remaining tooth tissue. Early diagnosis and monitoring Patients can barely detect early enamel erosion dueto its smooth and shiny appearance (Fig. 1). Evenwhen detected, they rarely seek treatment until itgets to an advanced stage when it either becomessymptomatic or affects the aesthetics of their teeth.The responsibility of early detection and initiation oftreatment of dental erosion, therefore, falls on thedental professionals. In the light of this, the first andthe most important step in a preventive strategywould be the development of and training of dentalprofessionals on techniques for the early diagnosisand monitoring of the progress of dental erosion.This would not only permit early institution oftreatment and preventive regimes including healtheducation and counselling but would also enable thepreventive regimes to be assessed scientifically andquantitatively. There is no diagnostic device avail-able at present for early clinical detection andquantification of dental erosion. However, someindices and techniques have been developed forcontinuing monitoring of the lesion status. TheSilicone Index described by Shaw et al. 27 (a siliconeputty impression of the teeth is taken in a sectionaltray), is one of the easiest and most useful methodsof monitoring tooth wear. The Tooth Wear Index ofSmith and Knight, 28 which records the degree ofwear on all tooth surfaces, allows monitoring of theeffectiveness of preventive measures. Serial (refer-ence) impression casts or study models rec-ommended by Wickens 29 can be used at follow upvisits for macroscopic comparison with the teeth tomonitor wear. Clinical photographs are obviouslyuseful for monitoring wear, but the dexterity of thephotographer and ambient conditions such as lightreflections affects the quality of the outcome.Although these indices and techniques are usefulfor estimating the extent and pace of the toothwear, they are not capable of quantifying themineral lost through erosion and the actual depthof tissue demineralization. Amaechi et al. 14,30 haveshown that the depth of an eroded lesion consists ofthe depth of the crater plus the depth of tissuedemineralisation at the base of the lesion (Fig. 2).It is pertinent to mention that the existence of thisdemineralisation pattern described by Amaechiet al. 14,30 is yet to be shown in naturally occurringeroded lesions-perhaps due to lack of a device forin vivo quantification 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  quantification, for in vitro and in situ studies, istransverse microradiography, 31 so there is still aneed for a system with clinical application.Once dental erosion is detected, there is a needfor full case history, which should include dietaryhistory, medical history, dental hygiene habits andlifestyle history. This would establish the aetiologi-cal factor, and help in development of individualisedcounseling. Preventive strategies Followingthe diagnosisofanearlylesionorpatient’ssusceptibility, the following recommendations maybe considered as a ‘damage-limiting’ as well aspreventive policy. Treatment of the underlying medical disorders and diseases.  Some patients may not be aware of theirunderlying medical condition, but in search oftreatment for the deteriorating condition of theirteeth. Therefore the dentist may be the firsthealthcare professional to detect an underlyingmedical disorder. 32,33 Some patients may not recog-nise their condition as a disorder, especially theanorexia/bulimia patients, and hence would notseek medical attention until it starts affecting theaesthetics,functionor‘comfort’oftheirteeth.Suchpatients should be referred to the appropriatespecialist (doctor or clinical psychologist) for propertreatment of their condition. Use of a remineralising agent.  It is a commonpractice among individuals to refresh their mouth bytoothbrushing with dentifrice after vomiting orregurgitation, as the case with an eating disorderorchronicalcoholism. Bearing inmind thatsofteningof tooth surface by acidic challenge decreases itswear-resistance, thus rendering it more susceptibleto the effects of mechanical abrasion, 34 someresearchers discourage toothbrushing as a means ofrefreshing the mouth after an acidic challenge.Instead, the use of time-delay technique (such asallowing at least 60 min before brushing) to achieveremineralisation by saliva alone is advised. 35–37 Although a softened enamel surface can beremineralised with exposure to saliva, 14,30,36 it hasbeen demonstrated that enamel surface softened byan erosive agent may be worn by abrasion fromthe surrounding oral soft tissues 16 and demastica-tion, 15,16,38–40 before it can be remineralised bysaliva, with consequent loss of tooth tissue softenedby erosion (Figs. 3a–c and 4a and b). Moreover, it isnot feasible to obtain patients’ compliance with atime-delay technique without the provision of analternative mouth refresher. It may be moreacceptable, practicable and easier to gain patients’compliance, if, following an acidic challenge, aremineralising agent could be administered immedi-ately to enhance rapid remineralisation of thesoftened tooth surface and also serve as a mouthrefresher. It may be advisable for individualssuffering from GORD to use a remineralising agenton waking from sleep. Graubart et al. 41 have showninvitrothata4-minpre-treatmentofanacid-etchedenamel surface with 2% sodium fluoride significantlyreduced the solubility of the enamel surface, whilethe application of sodium fluoride solutions immedi-ately before toothbrushing significantly reducedabrasion of eroded dentine in vitro. 42 The reminer-alisation of the eroded tissue has been reported toconfer a greater resistance to subsequent acidattack on the affected tooth surfaces. 37,42,43 The concentration of topically applied fluoriderequired to reduce subsequent demineralisation byerosion may differ from the recommended concen-tration for carious lesions, considering the differ-ences in their pathology, and the fact that fluoride isapplied for different purposes in these two con-ditions. Since an incipient caries lesion is a subsur-face lesion and the fluoride agent needs toeffectively diffuse through a relatively sound surfacelayer to remineralise the subsurface lesion, it isexpected that low fluoride concentrations appliedfrequently would be more suitable for caries.Imfeld 44 assumed that a high fluoride concentrationsmay promote the formation of a poorly permeableremineralised surface layer, thereby blockingenamel pores and reducing the ion exchange activityof surface enamel, and ultimately hindering Figure 2  Early enamel erosion showing lesion with anerosion crater and subsurface demineralisation X150. B.T. Amaechi, S.M. Higham246
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