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Understanding Risk Factors and Recommendations for Preventing Dental Erosion


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.)


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.  


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.)


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.


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.



Table 1: Table 1: Basic Erosive Wear Evaluation (BEWE), criteria for grading erosive wear





No erosive tooth wear


Initial loss of surface texture


Distinct defect, hard tissue loss <50% of the surface area


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*



Less than or equal to 2

Routine maintenance and observation

Repeat at 3-year intervals


Between 3 and 8

Oral hygiene and dietary assessment, and advice, routine maintenance and observation

Repeat at 2-year intervals


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


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

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