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Dental Erosion: Etiology, Diagnosis and Prevention a Peer-Reviewed Publication Written by Yan-Fang Ren DDS, Phd, MPH

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Dental Erosion: Etiology, Diagnosis and Prevention a Peer-Reviewed Publication Written by Yan-Fang Ren DDS, Phd, MPH Earn 3 CE credits This course was written for dentists, dental hygienists, and assistants. Dental Erosion: Etiology, Diagnosis and Prevention A Peer-Reviewed Publication Written by Yan-Fang Ren DDS, PhD, MPH PennWell designates this activity for 3 Continuing Education Credits. Publication date: April 2011 Go Green, Go Online to take your course Expiry date: March 2014 This course has been made possible through an unrestricted educational grant from Colgate-Palmolive Company. The cost of this CE course is $59.00 for 3 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. Educational Objectives Prevalence The overall goals of this article are to provide an overview of Dental erosion is a common condition, and its prevalence the causes, risk factors, diagnosis and prevention of dental ero- seems to be trending higher in recent decades.1 It is difficult to sion. On completion of this course the reader will be able to: accurately assess the prevalence of dental erosion from pub- 1. List and describe the prevalence of dental erosion lished literature, for there is not a universally accepted stan- 2. List and describe the etiologies of dental erosion dard for clinical evaluation of this condition. Dental erosion 3. List and describe the signs and symptoms of dental ero- is almost always complicated by other forms of tooth wear. sion and the complicating factors associated with dental The reported prevalence of dental erosion varies greatly in the erosion literature, which can be partially explained by age, country 4. List and describe methods for the management and and different evaluation standards. The median prevalence of prevention of dental erosion. dental erosion is 34.1 percent of children (interquartile range 27.4) and 31.8 percent of adults (interquartile range 18.7). In Abstract studies that reported prevalence of dental erosion in different Dental erosion is a prevalent condition that occurs worldwide. age groups, there is a clear trend of increasing prevalence with It is the result of exposure of the enamel and dentin to nonbacte- age in children and adults.2-6 Dental erosion has been consid- rial acids of extrinsic and intrinsic origin, whereby mineral loss ered a common condition limited to developed countries.1 occurs from the surface of the tooth. The most frequently af- fected areas are the palatal surface of maxillary incisors and the Etiology occlusal surface of the mandibular first molars in adolescents. Dental erosion is caused by sustained direct contact between Characteristic early signs of dental erosion include smooth and tooth surfaces and acidic substances. It has long been recog- flat facets on facial or palatal surfaces, and shallow and local- nized that demineralization of dental enamel will occur once ized dimpling on occlusal surfaces. Early intervention is key to the oral environmental pH reaches the critical threshold of effectively preventing erosive tooth wear. Effective prevention 5.5.7 Acids in the mouth originate from three main sources: of dental erosion includes measures that can avoid or reduce produced in situ by acidogenic bacteria, ingested extrinsic direct contact with acids, increase acid resistance of dental hard acids as dietary components and dislocated intrinsic acids tissues and minimize toothbrushing abrasion. through the backflow of gastric contents. Acids of bacterial origin cause caries, while extrinsic and intrinsic acids cause Introduction dental erosion. Clearance of acids from the oral cavity is, to a Dental erosion is the loss of dental hard tissue, associated large extent, dependent on the saliva flow rate and the saliva with extrinsic and/or intrinsic acid that is not produced by buffering capacity. Low saliva flow rate and poor buffering bacteria. Though the chemical process of dental erosion is capacity allow prolonged retention of extrinsic and intrinsic similar to that of caries, i.e., dissolution of hydroxyapatite by acids in the mouth, which will accelerate the erosive process. acids, the clinical manifestations and management of dental erosion are fundamentally different from caries because the Extrinsic acids erosive process does not involve acid of bacterial origin. Den- tal erosion does not begin as a subsurface enamel lesion that Acidic beverages is conducive to remineralization, as in the caries process, but Soft drinks, including carbonated beverages, fruit juices and rather as a surface-softening lesion that is susceptible to wear sport drinks, are almost exclusively acidic (pH<4.0) in nature and resistant to remineralization by conventional therapies. in order to maintain a fresh and fizzy mouthfeel (carbonated It is often widespread and may involve the entire dentition. beverages) and to prevent rapid growth of bacteria. Table 1 Dental hard tissue loss associated with erosion is almost lists the pH ranges of common beverages on the consumer always complicated by other forms of tooth wear such as at- market. These beverages, when in contact with the tooth, will trition and abrasion. Dental erosion results in tooth surface reduce the pH at the tooth surface to a level below the critical softening, which inevitably accelerates tissue loss caused by value of 5.5 for enamel demineralization. tooth-to-tooth contact while chewing and grinding (attrition) The effects of these beverages on dental hard tissues have or by abrasive wear while mechanically brushing or cleaning been extensively studied in recent years. Numerous experi- tooth surfaces (abrasion). If dental erosion is not managed mental and clinical investigations have shown that dental ero- through effective interventions, it may result in substantial sion in the form of enamel and dentin tissue loss can be caused loss of enamel and subsequent exposure of the underlying by carbonated soft drinks8-11, fruit juices12-16, sport drinks17-19 dentin, which can, in turn, lead to dentin sensitivity, loss of and wines.20-22 Erosion starts with enamel surface softening in vertical height and esthetic problems. the early stage, and enamel tissue loss develops progressively Effective management of dental erosion is largely depen- with continued erosive challenges. Softened enamel is suscep- dent on a thorough understanding of its etiology and early tible to abrasive wear. Brushing after erosive challenges will recognition of its signs and symptoms in clinical practice. accelerate enamel tissue loss.23-27 2 www.ineedce.com Table 1. pH values of common beverages28-30 Carbonated drinks pH Juice drinks pH Other drinks pH Coke 2.7 Orange juice 3.4 Iced tea 3.0 Pepsi 2.7 Grapefruit juice 3.2 Fanta orange 2.9 7-Up 3.2-3.5 Cranberry juice 2.3-2.5 Red Bull 3.4 Sprite 2.6 Apple juice 3.4 Gatorade 3.3 Mountain Dew 3.2 Pineapple juice 3.4 Isostar 2.4-3.8 Dr. Pepper 2.9 Kiwi juice 3.6 Coffee 2.4-3.3 Lemon Nestea 3.0 Grape juice 3.4 Tea (black) 4.2 Root beer 3.0-4.0 Carrot juice 4.2 Beer 4.0-5.0 Ginger ale 2.0-4.0 Beetroot juice 4.2 Wine 2.3-3.8 Acidic foods and dietary ingredients Intrinsic acids Besides acidic drinks, many solid and semisolid foodstuffs are The source of intrinsic acids in the oral cavity is mostly from also acidic in nature. Table 2 lists common foods and dietary the backflow of the gastric contents through the esophageal ingredients that have low pH values. Though the potential tract. Gastric juice consists mainly of hydrochloric acid, pro- erosive effects of acidic foodstuffs are not well understood, it duced by the parietal cells in the stomach. The presence of is believed that frequent ingestion of these types of foods may the highly acidic gastric juice (pH 1.0-3.0) in the oral cavity also contribute to dental erosion. may lead to dental erosion. Gastro-esophageal reflux disease Individual eating habits may be the most important factor (GERD), bulimia and rumination are the main conditions affecting the erosive potential of acidic foods. Frequent con- associated with the backflow of gastric juice to the mouth. sumption of citrus fruits could significantly increase the risk for Voluntary reflux of gastric contents (rumination) has been dental erosion.31 Persons with a diet with more fruits and acidic reported in special populations as a potential cause of dental berries may also have higher frequencies of dental erosion.32,33 erosion.47-49 Though it is rare in occurrence, rumination should be considered as one of the potential etiological factors in 28-30 Table 2. pH values of common foodstuffs patients with unknown causes of erosive tooth wear. Patients Fruits pH Other foodstuffs pH suffering from bulimia may ruminate multiple times daily over a prolonged period of time, which may cause typical dental Apples 2.9-3.5 Cranberry sauce 2.3 hard tissue loss on the palatal aspect of the maxillary teeth.50 Apricots 3.2-3.6 Fruit jams/jellies 3.0-4.0 The prevalence of dental erosion is higher in bulimic patients Blueberries 3.2-3.5 Italian salad dressing 3.3 than in non-bulimic controls.50,51 Dental erosion in bulimic Cherries 3.2-4.7 Ketchup 3.7 patients is most likely associated with oral retention of regur- Grapes 3.3-4.5 Mayonnaise 3.8-4.0 gitated gastric contents. The dietary habits of bulimic patients Grapefruits 3.0-3.5 Mustard 3.6 may include binging on high-energy foods and foods with high Lemons/limes 1.8-2.4 Pickles 2.5-3.0 erosive potential, which may further exacerbate erosion.51 Oranges 2.8-4.0 Relish 3.0 Peaches 3.1-4.2 Rhubarb puree 2.8 Saliva flow and buffering capacity Pears 3.4-4.7 Sauerkraut 3.1-3.7 When acidic substances enter the mouth, salivary glands will Pineapples 3.3-4.1 Sour cream 4.4 reflectively increase secretion and saliva flow will accelerate to Plums 2.8-4.6 Tomatoes 3.7-4.7 clear the acids from the oral cavity.
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