Understanding Risk Factors and Recommendations for Preventing Dental Erosion
Introduction
Tooth wear is a common problem in
dentistry and its diagnosis and management is controversial. Dental erosion is
the irreversible loss of dental hard tissue due to a chemical process of acid
dissolution. 1 Erosion is an independent
risk factor for development of caries and tooth loss and is increasingly seen
in younger age groups.
Thinning of the enamel is variably
referred to as attrition, abrasion, or erosion. Erosion is the more general
term, while attrition is considered to be consistent with the normal
age-related loss of the hydroxyapatite layer. On examination there is often evidence
of thinning and softening of the surface of teeth.
Etiology and prevalence of dental erosion
Dental erosions can result from
extrinsic or intrinsic factors. Extrinsic factors are those that lower the
ambient pH in the mouth and most commonly result from the consumption of acidic
foods and beverages. Intrinsic factors are those medical conditions resulting
in inadequate salivary production or excessive oral acid content. The most
common condition in this category is gastroesophageal reflux disease (GERD), where
abnormal amounts of gastric acid reflux into the oral cavity.2 Several chronic
medical disorders and medications are associated with impaired production of
saliva. The role of bruxism is not clear and several studies have shown
conflicting results.3 Studies have also
concluded that tooth brushing is probably not a significant contributor to
erosion.4
Teeth with normal enamel are quite
resistant to effects of direct trauma to the surface. Chronic, repetitive
rubbing of the tooth surface when enamel is softened results in focal loss of
enamel. Increased acid levels in the oral cavity soften enamel and break down
hydroxyapatite making enamel more susceptible to the effects of friction.5
Dental erosion has increased
dramatically since the introduction of sugary diets and soft drinks. In children
and adolescents prevalence is reported to be up to 50% and rising.3 In adults the enamel
seems to thin with age (attrition) and prevalence is as high as 90% of adults
with dental erosions.3
Clinical characteristics
Generally there are no symptoms in
early phases, but as erosions extend through the enamel surface sensitivity
develops. Patients may ultimately develop tooth decay and associated infections.
On examination early stages will
show no changes in color or softening of the tooth surface. As disease
progresses the tooth surface appears more dull and uneven with small
concavities. (See Figure 1) Most often the surface is slightly rounded or flat
and sometimes it gives a “melted” appearance.3 These changes are
most commonly seen on the palatal surfaces of the maxillary anterior teeth and
on occlusal surfaces of the lower first molars. (See Figure 2)
Diagnosis is made by direct
examination. The Basic Erosive Wear Examination (BEWE) scoring provides an
objective semiquantitative scoring method facilitating uniformity in reporting
and earlier intervention.5,6
(Table 1) Imaging techniques can be used to show earlier dental erosion.7-9 (See Table 1.)
Prevention
Since early diagnosis is difficult
and prevalence is so high, prevention is extremely important. Adequate oral
hygiene helps remove acidic foods and beverages, and practitioners can
emphasize a healthier selection of beverages including drinks with lower sugar
and acid contents. Fluoride and calcium supplementation are helpful in
prevention of dental erosions and in children promote remineralization, with fluoride
being more effective than calcium.1 Chronic medical
conditions should be controlled.
Treatment
Prevention is of paramount
importance. Regular dental visits can encourage the behavioral modification
needed when diet is contributing to dental disease. The BEWE provides
guidelines for treatment of erosive disease.6 (See Table 2) While
operative approaches requiring removal of tooth structure have little role in
absence of decay or pain, other methods including laminates and reconstructive
techniques are helpful in more advanced disease. (See Table 2.)
Conclusion
Dental erosion is an extremely
common dental condition whose cause is multifactorial. Early diagnosis is
difficult making prevention of paramount importance. Reduction in acidic diets
and drinks, good oral hygiene, fluoride supplementation, and regular dental
visits are the hallmarks of prevention. Many additive treatment strategies give
very satisfactory results in patients with advanced disease.
References
1. Zini A, Krivoroutski Y, Vered Y.
Primary prevention of dental erosion by calcium and fluoride: a systematic
review. Int J Dent Hyg. Feb
2014;12(1):17-24.
2. Song JY, Kim HH,
Cho EJ, Kim TY. The Relationship between Gastroesophageal Reflux Disease and
Chronic Periodontitis. Gut and liver. 2014;8(1):35-40.
3. Johansson AK,
Omar R, Carlsson GE, Johansson A. Dental erosion and its growing importance in
clinical practice: from past to present. Int
J Dent. 2012;2012:632907.
4. Isaksson H,
Birkhed D, Wendt LK, Alm A, Nilsson M, Koch G. Prevalence of dental erosion and
association with lifestyle factors in Swedish 20-year olds. Acta Odontol Scand. Nov 28 2013(0):1-10.
5. Vered Y, Lussi
A, Zini A, Gleitman J, Sgan-Cohen HD. Dental erosive wear assessment among
adolescents and adults utilizing the basic erosive wear examination (BEWE)
scoring system. Clin Oral Investig. Jan
14 2014:1-6.
6. Bartlett D,
Ganss C, Lussi A. Basic Erosive Wear Examination (BEWE): a new scoring system
for scientific and clinical needs. Clin
Oral Investig. Mar 2008;12 Suppl 1(1):S65-68.
7. Azarpazhooh A.
Radiographic Analysis of Acquired Pathological Dental Conditions. In: Basrani
B, ed. Endodontic Radiology. 2nd ed:
Wiley; 2012:153-165.
8. Rakhmatullina E,
Bossen A, Bachofner KK, Meier C, Lussi A. Optical pen-size reflectometer for
monitoring of early dental erosion in native and polished enamels. J Biomed Opt. Nov 2013;18(11):117009.
9. Harput
S, Evans T, Bubb N, Freear S. Diagnostic ultrasound tooth imaging using
fractional Fourier transform. IEEE
transactions on ultrasonics, ferroelectrics, and frequency control. Oct
2011;58(10):2096-2106.
Tables
Table 1: Table 1: Basic Erosive Wear Evaluation (BEWE), criteria for grading erosive wear
Score | Description |
0 | No erosive tooth wear |
1 | Initial loss of surface texture |
2* | Distinct defect, hard tissue loss <50% of the surface
area |
3* | Hard tissue loss >=50% of surface area |
*In scores 2 and 3 dentine often is involved
Table 2: BEWE Risk levels as a guide to clinical management
Risk level | Cumulative score of all sextants* | Management |
None | Less than or equal to 2 | Routine maintenance and observation Repeat at 3-year intervals |
Low | Between 3 and 8 | Oral hygiene and dietary assessment, and advice, routine
maintenance and observation Repeat at 2-year intervals |
Medium | Between 9 and 13 | Oral hygiene and dietary assessment, and advice, identify
the main etiological factor(s) for tissue loss and develop strategies to
eliminate respective impacts Consider fluoridation measures or other strategies to
increase the resistance of tooth surfaces Ideally, avoid the placement of restorations and monitor
erosive wear with study casts, photographs, or silicone impressions Repeat at 6–12-month intervals |
High | 14 and over | Oral hygiene and dietary assessment, and advice, identify
the main etiological factor(s) for tissue loss and develop strategies to
eliminate respective impacts Consider fluoridation measures or other strategies to
increase the resistance of tooth surfaces Ideally, avoid restorations and monitor tooth wear with
study casts, photographs, or silicone impressions Especially in cases of severe progression consider special
care that may involve restorations. Repeat at 6–12-month intervals |
*Cumulative
score based on sum of highest score of worst surface of all teeth in a given
sextant