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The Foundation to Any Clinical Approach

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Diagnosis and Detection

The Foundation to Any Clinical Approach

The Chemical Aspect of Tooth Wear

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Tooth wear is a predicament often presented by patients in need of full-mouth fixed rehabilitation. Frequent signs of deterioration with such patients may be increased interocclusal distance in conjunction with a shorter mandible, a reduced vertical dimension of occlusion, and tooth sensitivity.1 In order to prevent further deterioration of patients’ oral and dental conditions and to provide patients with predictable long-lasting restorations, the etiology of tooth wear must be predetermined prior to rendering treatment and causal factors must be identified and addressed. Etiology may be of mechanical (eg, attrition, abrasion, and abfraction) or chemical erosion which may be of intrinsic or extrinsic origin. Many times, patients will manifest with signs and symptoms which may be tracked to multifactorial causes.
Chemical erosion is the result of prolonged exposure of teeth to acidic dissolution. Common signs of erosion include:

  • Broad concavities within smooth surface enamel;
  • Cupping of occlusal surfaces;
  • Increased incisal translucency;
  • Wear on non-occluding surfaces;
  • Raised amalgam restorations; and 
  • Preservation of enamel cuff at the gingival crevice.2 

Extrinsic factors are related to the intake of acidic beverages, acidic foods, or exposure to environmental acids. Fruit juices, carbonated drinks, herbal teas, and sports drinks have been showed to be highly acidic. The duration and frequency as well as the method consumption are of major significance in terms of the lesions’ development. The higher the frequency of intake and duration of exposure, such as with swishing acidic or carbonated drinks back and forth in the mouth, the higher the likelihood of developing erosive lesions. However, drinking with a straw may reduce such a risk. One less common extrinsic factor is environmental or occupational exposure. Occupational exposure to acetic acid vapors from silicone sealers,3 full-time wine tasting4 and exposure to sulfuric acid mist in battery factories are reported to be associated with increased risk of tooth erosion. This affects predominantly the labial surfaces of the incisors.5,6

Regurgitation is the primary intrinsic cause of erosion, which occurs as a result of gastric acid entering the mouth voluntarily or involuntarily. Involuntary regurgitation may be a common complication from hiatus hernia and chronic alcoholism. Gastroesophageal reflux disease (GERD) may manifest typically with heartburn and regurgitation and may also cause tooth erosion. Commonly employed diagnostic tests for detecting GERD include barium swallow, endoscopy, and 24-hour pH monitoring. GERD can be sometimes difficult to treat. Medications such as proton pump inhibitors are recommended as standard treatment.7 Voluntary regurgitation is considered to be an eating disorder (eg, anorexia nervosa and bulimia nervosa), and the effect of gastric acid can be observed as localized lesions on the palatal aspects of maxillary posterior and maxillary anterior teeth, and on the buccal surfaces of mandibular posterior teeth in patients with eating disorders. With bulimia nervosa patients, additional cervical lingual lesions can be detected on the mandibular anterior teeth in conjunction with incisal erosion.8
Once the early signs of tooth wear are recognized, individual prevention can be initiated once the etiology of erosion has been identified. If the erosive factor is intrinsic, the diagnosis and treatment of the underlying condition is a pre-requisite. The patient should be referred to a physician for diagnosis and treatment. If the erosive factor is extrinsic, patient education and lifestyle changes are required to control additional tooth surface loss. A healthy diet and eating habits will help to reduce tooth wear. The quality and quantity of saliva are considered as important modifiers. Sugar-free diet or consumption of xylitol containing products instead of sugar, have also been shown to be effective in the prevention of tooth surface loss.9

Early detection of signs and symptoms of erosion and recognition of the etiology are critical for proper diagnosis and treatment. Such diagnosis by clinicians working in conjunction with other professionals is essential for managing and preventing further damage to patients’ dentition. An individualized prevention protocol must be established based on the input of all involved professionals such as physicians, dietary consultants, and dental professionals.

*Associate Professor and Director, Graduate Prosthodontics. Department of Restorative Dentistry, University of Washington, Seattle, Washington.
Assistant Professor, Department of Restorative Dentistry, University of Washington, Seattle, Washington.


  1. Verrett RG. Analyzing the etiology of an extremely worn dentition. J Prosthodont 2001;10(4):224-233. 
  2. Gandara BK, Truelove EL. Diagnosis and management of dental erosion. J Contemp Dent Pract 1999;1(1):16-23. 
  3. Johansson AK, Johansson A, Stan V, Ohlson CG. Silicone sealers, acetic acid vapours and dental erosion: a work-related risk? Swed Dent J 2005;29(2):61-69.
  4. Wiktorsson AM, Zimmerman M, Angmar-Månsson B. Erosive tooth wear: Prevalence and severity in Swedish winetasters. Eur J Oral Sci 1997; 105(6): 544-550.
  5. Petersen PE, Gormsen C. Oral conditions among German battery factory workers. Community Dent Oral Epidemiol 1991; 19(2): 104-106.
  6. Kelleher M, Bishop K. Tooth surface loss: An overview. Br Dent J 1999;186(2):61-66. 
  7. Vaezi MF. Atypical manifestations of gastroesophageal reflux disease. MedGenMed. 2005;7(4): 25.
  8. Valena V, Young WG. Dental erosion patterns from intrinsic acid regurgitation and vomiting. Aust Dent J 2002;47(2):106-115.
  9. Milgrom P, Rothen M, Milgrom L. Developing public health interventions with Xylitol for the US and US-associated territories and states. Suom Hammaslaakarilehti. 2006;13(10-11):2-11.

I see wear in surprising frequency among my clinic patients and running through these indications is helpful thanks!
CalvGrov at 2/28/2011 7:50 AM

What about environmental factors?
JeffD at 2/28/2011 2:04 PM

Great stuff!
John Span at 5/6/2011 5:13 PM

Does anyone have additional links or resources they can share on GERD?
John Span at 7/10/2011 8:00 PM

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