(10) dental erosion


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(10) dental erosion

  1. 1. Case (1) Dental Erosion Literature Review Feda Zawaideh 1 INTROUDUCTION Tooth wear or tooth surface loss is a general term used to describe the non-carious loss of tooth structure.1 Tooth wear can be considered either physiologic or pathologic. It is considered pathologic when the teeth become so worn that they can not function efficiently, the aesthetics are affected and the longevity of the teeth involved is compromised.2 Based on the aetiological factor and clinical manifestations, tooth wear is subdivided into attrition, abrasion, abfraction and erosion. (Table 1) Table 1: Definitions of attrition, abrasion, abfraction and corrosion Attrition The physiological wearing of teeth resulting from tooth to tooth contact with or without the presence of an abrasive substance between the teeth1 Abrasion The physical wear of tooth surface through a mechanical process caused by factors other than tooth to tooth contact1 Abfraction Wedge-shaped defect at the cementoenamel junction of a tooth caused by eccentrically applied occlusal forces leading to tooth flexure3 Erosion The progressive loss of hard dental tissues by a chemical process not involving bacterial action1 Dental erosion is becoming an increasing problem due to the increased exposure to the elements that cause dental erosion. Dentists and dental specialist need to be more aware of the potential for dental erosion to occur, the possible aetiological factors, the presentation and management of the condition. DENTAL EROSION Dental erosion or as currently termed corrosion may be defined as tooth tissue loss from chemical dissolution of teeth by acids other than those produced by bacteria.4 Ten Cate and Imfeld (1996) defined this clinical term as “the physical results of a pathologic, chronic, localized loss of dental hard tissue that is chemically etched away from the tooth surface by acid and/or chelation without bacterial involvement.5
  2. 2. Case (1) Dental Erosion Literature Review Feda Zawaideh 2 CLINICAL PRESENTATION The surfaces of teeth most commonly affected with erosion are the palatal and occlusal surfaces of maxillary teeth, as well as the buccal and occlusal surfaces of posterior mandibular teeth. Initially erosion may be evident as dullness or matt appearance of the enamel seen when the tooth surface is clean and dry. The lesion progresses to a concave loss of tooth structure with wide, smooth and shiny margins that usually lacks developmental ridges and stains and is often plaque free. As erosion continues the underlying yellow dentine begins to show through. Due to differential wear, cupping lesions on the cusp tips of the occlusal surfaces of posterior teeth may occur as the dentine is lost more quickly than the surrounding enamel.6,7,8 Amalgam and composite restorations are not affected by erosion and therefore appear “proud” of the surrounding dental tissues. Erosive lesions occur commonly on the palatal surfaces of maxillary anterior teeth. The lesions present as a central area of exposed dentine surrounded by sound enamel at the gingival margin.8 This is attributed to the buffering capacity of the gingival crevicular fluid that constantly bathes that area. The teeth are often sensitive to touch and to temperature changes and the loss of tooth surface is disproportionate to the age of the patient.6 Advanced erosion can lead to pulpal, functional and aesthetic problems.6 Tooth substance loss is often multifactorial in aetiology resulting from a combination of attrition, abrasion and erosion. Dental erosion is rarely the sole operating factor but it can be considered a predominant factor. Erosion is believed to cause enamel surface demineralization that makes the tooth surface softer and more susceptible to mechanical wear by attrition and abrasion.9 For example, the surfaces affected by erosion are frequently subjected to shear forces either from the surrounding oral soft tissues as the keratinized dorsum of the tongue during speech and swallowing (palatal surfaces) or through food mastication (occlusal surfaces) or from external sources such as tooth brush and toothpaste abrasives.10 The association of dental erosion and attrition was shown in a study involving the assessment of wear in 104 patients in South East Queensland. Khan et al (1998) found that even if a patient is suspected to having bruxism, erosion may be the more likely cause of hard tissue loss than attrition alone in most cases.11
  3. 3. Case (1) Dental Erosion Literature Review Feda Zawaideh 3 PREVALENCE OF DENTAL EROSION The exact prevalence of dental erosion is unknown although there is general agreement that it is significantly high and increasing continuously, especially in the young. It is believed that the prevalence in children and adolescents range from 5- 57%. The difficulty in determining the prevalence arises from the diversity of indices used in the measurement of tooth wear, the inability to isolate erosion cases since the majority of cases have a multifactorial aetiology. Measurement of tooth wear by erosion is made difficult by the absence of stable reference points on the tooth surfaces. A review of the techniques available to measure tooth wear and erosion showed that none of them is ideal.12 Clinical methods of measurement rely on visible changes on study casts or the comparison of photographs over time. The techniques are inaccurate but are sufficient to determine the need for treatment.12 Tooth wear indices have been suggested to evaluate the prevalence of erosion or tooth wear in a population for epidemiological studies. The most commonly used is the modified Smith and Knight Tooth wear index. Unfortunately, the index is still subjective and insufficiently sensitive to detect small amounts of tooth wear.13 Table 2: Smith and Knight tooth wear index14
  4. 4. Case (1) Dental Erosion Literature Review Feda Zawaideh 4 The largest epidemiological study of dental erosion in the United Kingdom was the National Children’s Dental Health Survey of 1993.15 In the study the maxillary incisor teeth of a representative random sample 5-15 year olds were scored using the modified Smith and Knight index. The study found that 52% of 5 year olds had erosion on the palatal surfaces of their primary incisors, and nearly a quarter of these cases had progressed to the pulp. Of the 12 year old children, 27% had evidence of erosion on their incisors with about 2% of these cases had progressed to the pulp. The 2000 National Diet and Nutrition Survey (NDNS) of young people aged 4-18 years showed that 58% of 4-6 year olds were affected with dental erosion. Table 3 summarizes the prevalence studies of tooth erosion in children in the UK.15 Table 3: Prevalence studies of tooth erosion/wear in children resident in the United Kingdom14 A recent study that investigated the prevalence of tooth erosion in 2000 children 12 year old found that 59.7% of the children were affected with 2.7% exhibiting dentine exposure. Significantly more boys were affected than girls and more Caucasians than
  5. 5. Case (1) Dental Erosion Literature Review Feda Zawaideh 5 Asian children.15 There is some evidence that socio-economic status has an influence on the prevalence of erosion, although this is not conclusive (refer to table 4). Table 4: Socio-economic status and prevalence of erosion14 It appears that those with low socioeconomic status have more erosion than those with high socioeconomic status. It is suggested that this may have some relationship to oral hygiene practices and diet as children of higher socioeconomic status could have better oral hygiene practices than those of low socioeconomic status and a more acidic diet.15 Deery et al (2000) conducted a study in the United States (129 subjects) and in the United Kingdom (125 subjects) using the same examiners and based on the same criteria. The prevalence was found to be 41% and 37% in 11-13 year old respectively. The results indicated that there was no difference in the prevalence of dental erosion between the two countries and that the disease is quite significant.16 The possibility of erosion and dental caries occurring simultaneously can not be excluded. In fact this trend is being noticed more frequently as the use of acidic and sugar-containing drinks along with poor oral hygiene. The differences between the two conditions include the pathogenesis, the rate at which the disease progresses and occurrence in plaque-covered and plaque-free areas.17
  6. 6. Case (1) Dental Erosion Literature Review Feda Zawaideh 6 AETIOLOGY OF DENTAL EROSION Dental erosion is a multifactorial condition. Shaw & Smith (1998) constructed a VENN diagram similar to that of dental caries to explain its aetiology (Figure 1).4,18 The contributing factors have been suggested as having susceptible teeth, time as well as sources of extrinsic and intrinsic acids. The overlapping between the factors produces dental erosion. Identifying the aetiology of dental erosion is important as it increases the possibility of successful treatment and prevention of further wear. The pH of the oral cavity affects the solubility of the dental tissues. The solubility of teeth is believed to increase by 7-8 folds with each decrease of Ph when the pH falls below 6.5. It is believed that it is the actual H+ concentration of the acidic substance available to interact with the tooth that is more important than the pH. The type of acid, its chemical and physical properties determine its salivary clearance from the oral cavity.19 Erosion from intrinsic sources Intrinsic causes for erosion are gastric acids regurgitated into the esophagus and mouth. The pH content of the stomach acids is below 1.0, which is potentially damaging to the teeth. It has been estimated that this damage does not occur unless gastric acids have been acting on the dental tissues for once per week or more over a period of at least one to two years.20 Conditions in which there is chronic vomiting include disorders of the upper gastrointestinal tract, specific metabolic and endocrine disorders, central emetic side effects of medications (chemotherapeutic agents, histamine and tetracycline), alcoholism, drug abuse and certain psychomotor disorders such as stress-induced vomiting, anorexia and bulimia nervosa.4 Gastro-esophageal reflux disease (GERD) is an important cause of dental erosion. GER is defined as the passage of gastric contents into the esophagus while GERD is the symptoms or complications of GER.21 It is a common condition with a prevalence ranging from 6-10% although up to 59% of the population reports heartburn monthly, up to 20% report weekly symptoms and 18% use prescription drugs to manage their
  7. 7. Case (1) Dental Erosion Literature Review Feda Zawaideh 7 symptoms.21,22 The principal causes of gastro-esophageal reflux include sphincter incompetence as in cases of hiatus hernia, drugs as diazepam, neuromuscular causes as in cases of cerebral palsy and oesophagitis caused by alcohol. Increases gastric pressure as in the cases of obesity can be a cause of the reflux, in addition to increased gastric volume after a heavy meal, as result of obstruction and a spasm outcome.4 Symptoms of reflux in children and adults are listed in table 5. However, GERD can also be silent.22 Table 5: Signs and symptoms of Gastro-esophageal Reflux Disease22 Common Symptoms in Adults Common Symptoms in Children  Acid taste in the mouth  Difficulty sleeping  Persistent coughing  Failure to gain weight  Vomiting  Feeding problems  Sense of lump in the throat  General irritability  Stomach ache  Asthma  Sore throat  Recurrent pneumonia  Hoarseness of voice  Anemia  Choking spells  Bronchitis  Voice change  Laryngitis  Excess salivation  Gastric pain on awakening  Halitosis  Belching  Heartburn In children, physiological regurgitation of infancy resolves by 1 year of age unless the child has an underlying medical condition, such as failure to thrive, feeding problems or pneumonia. Erosion of primary and permanent teeth in children has been reported though not to the same extent of that in adult patients with GERD. This might be because children with GER tend to avoid acidic and carbonated foods as they aggravate their symptoms. These children may also be refluxing into the esophagus and not into their mouths and the success of medical treatment may contribute to the prevention of the reflux.22 A high incidence of GERD has been reported in children with cerebral palsy. It was even found that it is more important in the aetiology of tooth wear than parafunctional habits.23 On the other hand, O’Sullivan et al (1998) and Jensdottir et al (2004) concluded that dental erosion might not be as great a problem in children with GER as it is believed to be.24,25
  8. 8. Case (1) Dental Erosion Literature Review Feda Zawaideh 8 There is yet no single test that can consistently detect GERD, although depending on the clinical situation, reflux can be demonstrated with several diagnostic tests such as barium esophagography, endoscope examination, esophageal acid perfusion, measurement of lower esophageal sphincter pressure, mucosal biopsy and standard acid reflux test.21 The most useful diagnostic tool currently available to diagnose GERD is 24-hour monitoring of esophageal pH by means of a catheter passed through the nares to a point 5cm above the lower esophageal sphincter. If the PH in the distal esophagus remains below 4.0 for more than 4% of the time, the condition is considered pathologic.21 Treatment of GER includes a medical and non-medical approaches outlined in table 6 and 7.21 Table 6: Non-medical treatment for GERD 21 Table 7: Medical therapy for GERD21 The term eating disorder includes anorexia nervosa and bulimia. Each illness involves preoccupation with control over body weight, eating and food. They have a marked prevalence in females relative to males (F: M ratio of 10:1).26 Anorexia may be
  9. 9. Case (1) Dental Erosion Literature Review Feda Zawaideh 9 defined as “aversion to food resulting from a complex interaction between biological, social, individual and family factors leading to severe weight loss”.27 The average age of presentation for this condition is 16 years and a continuously increasing prevalence of 0.2%. The prevalence is under-estimated because relatively few women seek treatment. The condition involves conscious dietary restriction with consequent loss of weight and it may involve stages of binge eating and vomiting. Bulimia, on the other hand, is more common than anorexia with a prevalence of about 1% and a 25 year age of presentation. The condition involves continuous binge eating and subsequent induced vomiting in a way to lose weight.27 The median duration of these illnesses is up to 6 years with significant mortality (4-20%) from medical complications and suicide in anorexia.27 Callus formation on the back of the hand and fingers from putting the hand in the mouth to induce vomiting can be present and is called Russell’s sign.27 Oro-dental manifestations of eating disorders vary in severity according to the length of time the person had the eating disorder. In general dental erosion, caries, salivary gland hypertrophy and xerostomia along with moderate periodontal destruction and damage of the oral mucosa have been described.26 Erosion in patients with eating disorders is mainly due to the induced vomiting and to the high dietary intake of low pH beverages and fresh fruits. The characteristic distribution of erosion may lead to the diagnosis of the condition. It is characterized by increased erosion on the palatal surfaces of upper anterior teeth then extending to the occlusal and facial surfaces of upper and lower teeth. They usually exhibit increased level of lower posterior wear on the buccal and occlusal surfaces than other patients. The frequency, duration and total number of vomiting episodes are not linearly associated with erosion.28 Patients with eating disorders brush their teeth more frequently especially after vomiting episodes thus exacerbating the wear by abrasion.29 A study by Milosevic and Dawson (1996) analyzing the salivary factors in bulimics with or without pathological tooth wear, found that those with tooth wear had more viscous saliva and less bicarbonate in their saliva. In addition the salivary flow rates were less than normal which predisposes the patients to more dental erosion.29
  10. 10. Case (1) Dental Erosion Literature Review Feda Zawaideh 10 Erosion from extrinsic sources The extrinsic factors that cause dental erosion can be grouped under environmental, medications, diet and lifestyle headings. Environmental This type of erosion involves the exposure to acids in the workplace or during leisure activity, as in employees in factories manufacturing dynamite, batteries, galvanized products and fertilizers. Swimming in gas-chlorinated pools, professional wine tasters and printers may also be subject to erosion.19 Athletes involved in sporting activities causing dehydration followed by consumption of acidic sports drinks also place themselves at risk of dental caries.30 Medications In general, any medication that has a low pH and comes in frequent and/or sustained contact with teeth has the potential to cause dental erosion. Medications that have been implicated in causing erosion are those with low pH (range 1.5-8.6) like iron tonics, chewable vitamin C tablets, acid replacements or acid used for dissolving renal stones.31 Drugs inhaled to combat asthma may have a pH low enough to cause enamel dissolution and expose patients to dental erosion.32 Asthmatic individuals have been proven to have an increased prevalence and increased risk of dental erosion. A non- blind case control study of 4-10 and 11-16 year old British school children concluded that asthmatic children had more tooth erosion than their healthy peers. In the first age group, 61.5% with asthma had tooth erosion of the primary teeth compared to 44.3% prevalence in children without asthma. The labial surfaces were significantly more affected than the palatal surfaces.33 The authors attributed the greater tooth substance loss to the reduction of salivary flow (due to the beta 2 agonist medications) and the frequent consumption of acidic drinks on a regular basis as these children were thirstier than their siblings as reported by their parents.33 In a case control study conducted in south east Queensland, higher incidence of erosion was found in asthmatic children but the study did not exclude intrinsic causes as another source of the erosion.34 However, a study undertaken in Leicestershire and Rutland failed to demonstrate this relationship and failed to demonstrate any significant differences in erosion prevalence between asthmatic and non-asthmatic children.32
  11. 11. Case (1) Dental Erosion Literature Review Feda Zawaideh 11 Beta 2 adrenoreceptors are actually believed to promote fluid consumption, reduce salivary protection of enamel, reduce salivary flow and buffering capacity and may relax the esophageal sphincter predisposing patients to dental erosion. Diet The consumption of acidic food and beverages has been proved to be closely associated with dental erosion.35 Acidic drinks, either as fruit juices or as carbonated soft drinks with added organic and phosphoric acids are the most frequently cited reason for dental erosion in children.6 Citric acid can chelate calcium in hydroxyapatite, forming soluble citrates. Alcohol drinks as beer and wine have a low pH and would predispose to dental erosion. The intake of pickled food which normally has very high titratable acidity would also result in erosion.6 The method of intake of the erosive drink can influence the erosive potential. Edwards et al (1998) conducted a clinical study in a dental school in the United Kingdom using videofluoroscopic equipment to compare the potential influence of straw or cup drinking on dental erosion.36 The study demonstrated that drinking through a narrow bore straw placed more posterior behind the maxillary anterior teeth reduced the contact of the erosive drink with the teeth.36 Based on these results, Edwards et al (1998) recommended the following dietary advice:36 1. All fizzy drinks, fruit juices, diluting juices and flavored mineral waters are acidic and cause dental erosion. Safe drinks are water and milk. (The authors recommend tea and coffee but there is a possibility that caffeine causes dental erosion). 2. It is important to cut down on acidic drinks especially the number of times every day that these drinks are taken. If you have to have these drinks the best time is at mealtimes. 3. It is better to swallow the drink quickly to reduce the time it spends in your mouth. Avoid rinsing with the drink before swallowing. Drinking through a narrow straw placed behind the front teeth prevents contact of the drink with the teeth. 4. Brushing your teeth immediately after having an acidic drink can cause the teeth to wear more quickly. Avoid brushing for at least an hour after having soft drinks and try to brush with a less abrasive type of toothpaste preferably a
  12. 12. Case (1) Dental Erosion Literature Review Feda Zawaideh 12 gel-type and use a fluoride mouthwash. (The use of fluoride applied on the enamel even in acidic preparations reduces enamel erosion; however, the actual clinical benefit appears low but still recommended).37 The potential dental erosiveness of the beverages depends on different chemical characteristics. It is the titratable acidity of the beverage not the pH that gives a better guide to that potential. Baseline pH values give only a measure of the initial hydrogen ion concentration and provide therefore no indication as to the presence of undissociated acid.38 Titratable acidity, on the other hand, is the amount of alkali that is required to add to an acid to bring it up to a neutral pH. It represents the amount of available acid and is an indication of strength and erosive potential. The following table represents the pH, titratable acidity and erosion potential of the most commonly consumed acidic drink.4 Table 8: The pH, titratable acidity and erosion potential of drinks pH Titratable acidity Erosion potential Cola drinks 2.5 0.7 Medium Carbonated orange 2.9 2.0 Medium Grapefruit juice 3.2 9.3 High Apple juice 3.3 4.5 High White wine 3.7 2.2 Medium Orange juice 3.8 4.5 High Beer 3.9 0.6 Low Lager 4.4 0.5 Low Sparkling water 5.3 0.1 low Cairns et al (2002) investigated the effect of dilution on the erosive potential of acidic drinks. The results indicated that dilution had very little effect on the measured pH values but the titratable acidity fell considerably reducing the erosive potential of the drink.38 Unfortunately, the dilution ratios for the commonly available drinks were immense that they were not applicable to the range of concentrations consumed. Another factor that affects the erosion potential of the drink is the type of acid in the drink. It is believed drinks containing citric acid are more erosive than ascorbic acid or carbonic acid because of the high calcium chelating ability of the acid. This increases the erosion potential not only by chelating of calcium from the
  13. 13. Case (1) Dental Erosion Literature Review Feda Zawaideh 13 hydroxyapetite but by binding to the calcium ions in saliva thus reducing the degree of calcium available for remineralization and favor demineralization.39 Other factors that are believed to influence the erosive potential of acidic beverages are the buffering capacity of the drink and the ions present in the drink: the calcium and phosphate concentrations, fluoride concentration and the addition of xylitol to the drink.40,41 More recently, Ramalingam (2001) found that the erosiveness of sports drinks can be reduced by the addition of low concentrations of CPP-ACP (0.09%, 0.125% and 0.25%).42 Lifestyle There have been recent changes in the lifestyles and behavioral factors of the western population that are considered important in the aetiology of dental erosion. Recently, there is an increased emphasis on healthy dieting, increased consumption of raw fruits and acidic sports drinks along with increased consumption of acidic drinks by children.43 In addition to healthier diet, whiter teeth are sought through frequent oral hygiene practices even after the consumption of acidic drinks which predisposes to tooth wear. The use of anti-calculus acidic agents is believed to causes dental erosion but this has not been proved yet. Pretty et al (2003) conducted an in vitro study to establish the erosive risk of a number of mouth rinses currently on the market.44 It is the fluoride content and the buffering capacity of the mouth rinses that determine their erosive potential. In the study all but Listerine (pH 3.87, F− 0.021ppm) had no buffering capacity and were readily neutralized. A small degree of erosion was noted after the use of Listerine mouthwash.44 However, it was noted following 14 hours of application which is not likely to happen in vivo but this shows the need to recommend only short term use of mouthwashes post brushing and not before. Conversely there are unhealthy lifestyles that may be implicated in dental erosion as the use of the drug ‘ecstasy’ (3,4 methylenedioxy-methamphetamine) which is known to reduce the salivary flow and expose the individuals to dental erosion.4
  14. 14. Case (1) Dental Erosion Literature Review Feda Zawaideh 14 MODIFYING FACTORS OF DENTAL EROSION Individual’s susceptibility to dental erosion varies considerably depending on the presence of other predisposing and modifying factors. Among these factors are the morphology of teeth, the presence of any soft tissue defects and saliva properties.19 The surfaces in contact with the tongue, particularly the palatal surfaces of the maxillary teeth are much more affected by erosion than any other surface. The manner in which the erosive fluid is taken into the mouth, as in the habit of swishing the erosive drink around, may affect the extent and distribution of the erosive lesions depending on the surfaces it comes into contact with and the duration of contact.19 Salivary factors; the salivary flow rate, the buffering capacity and neutralization of dietary acids, oral clearance as well as the presence of the acquired salivary pellicle, are known to be intrinsic modifying factors of dental erosion.45 Sanchez and De Preliasco (2003) conducted a case control study using standard salivary tests to assess saliva characteristics, salivary pH, flow rate and buffering capacity in 30 children with erosive lesions before and after soft drinks intake and compared these to equivalent values for healthy caries-free individuals.45 Low salivary flow rate, low carbonate production and low buffering capacity and low pH after acidic drink consumption were significantly less in the control group. The results clearly indicate the greater potential for erosive damage when the normal protective roles of the saliva are reduced.45 This relationship has been clearly demonstrated and described by Gudmnundson et al (1995) and by O’Sullivan and Curzon (2000) in previous studies.46,47 The salivary pellicle on the enamel surfaces of teeth is also thought to act as a permeability-selective membrane providing protection against demineralization from erosive challenges.48 In vitro studies showed that the lubricating properties of the viscous mucin glycoprotein and the salivary pellicle derived from the submandibular/sublingual saliva provides enamel with the greatest and most prolonged protection from acid dissolution.48 In addition, enamel specimens coated with pellicle in in vivo studies revealed less extensive erosion of the enamel surface compared to uncovered specimens.48 The rate of formation of the acquired pellicle
  15. 15. Case (1) Dental Erosion Literature Review Feda Zawaideh 15 and its thickness that can be reduced with tooth brushing are also important contributing factors in the protection against erosive challenges. DIAGNOSIS OF EROSION Given the current state of knowledge of the causes of erosion and keeping in mind the possibility of associated attrition and abrasion, Gandara and Truelove (1999) proposed the following protocol for patient assessment and diagnosis of dental erosion.22 Table 9: Patient assessment and diagnosis of dental erosion I. Obtain historical data. Check for following items: Medical History  Excessive vomiting, rumination  Eating disorder  Gastroesophageal reflux disease  Symptoms of reflux (Table 5)  Frequent use of antacids  Alcoholism  Autoimmune disease (Sjogren's)  Radiation tx of head and neck  Oral dryness, eye dryness  Medications that cause salivary hypofunction  Medications that are acidic Dental History  History of bruxism (grinding or clenching) -Grinding bruxism sounds during sleep noted by bed partner? -Morning masticatory muscle fatigue or pain?  Use of occlusal guard Dietary History  Acidic food and beverage frequency  Method of ingestion (swish, swallow?) Oral Hygiene Methods  Toothbrushing method and frequency  Type of dentifrice (abrasive?)  Use of mouthrinses  Use of topical fluorides Occupational/Recreational History  Regular swimmer?  Wine-tasting?  Environmental work hazards? II. Perform physical assessment. Observe for following features: Head and Neck Examination  Tender muscles (bruxism?)  Masseteric muscle hypertrophy (bruxism?)  Enlarged parotid glands (autoimmune disease, anorexia, alcoholism) Intra-oral Examination  Signs of salivary hypofunction: -Mucosal inflammation -Mucosal dryness -Unable to express saliva from gland ducts  Shiny facets or wear on restorations
  16. 16. Case (1) Dental Erosion Literature Review Feda Zawaideh 16  Facial signs of alcoholism: -Flushing, puffiness on face -Spider angiomas on skin (bruxism?)  Location and degree of tooth wear (document with photos, models, radiographs General Survey  Underweight (anorexia) Salivary function assessment  Flow rate  pH, buffer capacity ( use of ‘Saliva Check Buffer’ GC corporation) Once diagnosed, it is important to record the location and severity of tooth erosion. Complete record with study models and intra oral photos need to be taken to monitor the progression of the condition (recommend localized silicone impressions and accurate study models in high density die-stone).4 MANAGEMENT OF EROSION Tooth wear could result in an aesthetic problem, loss of tooth structure, sensitivity and pain, pulpal exposure and loss of vertical dimension which is thought to lead to temporomandibular joint problems. The first step in the management of dental erosion is to determine the cause of the dental erosion and to identify the associated risk factors and where possible eliminated. The management of dental erosion involves a preventive and a restorative part and in this seminar it will be discussed in three phases; immediate, provisional and long term.49 Immediate management The cause of the dental erosion should be investigated thoroughly as previously mentioned, and eliminated whenever possible. Recording the clinical situation is an important step to allow further monitoring of the condition. Impressions, study models and photographs should be obtained before commencement of treatment. Prevention of ongoing erosion comes next and this can be undertaken by reducing the exposure to acid and enhance the ability of the oral cavity to overcome and resist the effect of the acidic environment.49
  17. 17. Case (1) Dental Erosion Literature Review Feda Zawaideh 17 Dietary counseling should be given after a thorough analysis of the diet. It must be personalized to the individual bearing in mind the constraints that are operating on them. It needs to be given in a positive, individualized way to maximize compliance.4 The patient needs to educated about the types of food and drinks that have the greatest erosive potential, encourage the consumption of positive alternatives as water, milk, tea, coffee without sugar because they are safer. Limitations should be placed on the time of consumption of the drinks, preferably during mealtimes. Drinks should be swallowed quickly without holding the drink in the mouth and preferably avoiding the use of sipping, pop tops and spout sups. In response to the increasing concern about dental erosion, product modifications have been attempted to minimize the effect of dental erosion. Mahoney and Kilpatrick (2004) reported three approaches mentioned in the literature.49 The first involves raising the pH, reducing the titrateable acidity and adding calcium to the soft drinks followed with the addition of hydrocolloid food gum. An example of this product is Ribena ToothKind drink (Ribena, Glaxo Smithkline, UK). The second approach is to add large amounts of calcium fluoride to soft drinks with the aim to supersaturate the environment around the tooth. Unfortunately this technique is less effective than the first one. Finally, minimal amounts of caseine phosphopeptide-amorphous calcium phosphate (CPP-ACP) added to sports drinks (Powerade) have been shown in vitro to reduce the erosive effect of the drink.42 Improving the resistance of the oral cavity to the effects of erosion can be achieved by increasing the resistance of the tooth tissue to dissolution or by improving the saliva function. The use of topical fluoride has been advocated to enhance the tooth resistance to dissolution. The suggested method of action of fluoride in erosion prevention involves the deposition of fluoride in the porous structure of dentine acting as a diffusion barrier preventing further dissolution.50 Bardsley et al (2004) demonstrated that children in non-fluoridated districts are 1.5 times more likely to have smooth surface wear compared with children in fluoridated districts.51 In addition, the use of fluoride twice a day in the form of toothpaste provided added protection from dental erosion.Another option involves the use of CPP-ACP in the form of a sugar free gum (Recaldent) or as a topical cream (Tooth Mousse).
  18. 18. Case (1) Dental Erosion Literature Review Feda Zawaideh 18 To neutralize the acidic attack after vomiting or reflux sucking sugar free antiacid tablets can be recommended. Rinsing with sodium carbonate or baking powder is mentioned in the literature but with no specific scientific reason. The use of custom trays as a method of application is also suggested.52 However, using the trays at night in patients with reflux may result in trapping acid within and causing more erosion. Immediate management of dental erosion also involves the management of any sensitivity and pain experienced by the patient. The use of glass ionomer cement as a sealant will actually resolve the sensitivity and will prevent further damage.53 Anecdotally, dentists have been using Tooth Mousse applied on a cotton bud or Gel Kam to reduce the sensitivity. Interim treatment Any restorative treatment should be ideally delayed until the effect of the preventive measures on the rate of tooth wear is assessed. In cases where function or aesthetic is compromised active treatment is recommended. Treatment should be aimed at restoring the missing tooth structure with minimal intervention, preventing further tooth tissue loss and maintaining a balanced occlusion. The table below memorizes the techniques currently available to restore teeth affected by dental erosion. Table 10: Treatment options for the management of dental erosion49 Material Advantages Disadvantages Durability Cast Metal (nickel chrome or gold) Fabricated in thin sections- require only 0.5mm space Very accurate fit possible Does not abrade the opposing dentition Protective of residual tooth structure May be cosmetically unacceptable due to the shine through of metallic grey Can not be simply repaired or added to intraorally Suitable for posterior restorations in parafunction?? Multiple appointments required Success rate of 89% for palatal veneers over 4.5 years (n=210) Composite- Least expensive Technically difficult for Success rate of 86% for
  19. 19. Case (1) Dental Erosion Literature Review Feda Zawaideh 19 direct May be used as a diagnostic tool Can be added to and repaired relatively simply intraorally Aesthetically superior to cast metal Single appointment palatal veneers Limited control over occlusal and interproximal contour Requires minimum of 1mm space Possible inadequate wear resistance for posterior use labial veneers over 3 years (n=289) Composite- indirect Can be added to and repaired intraorally Aesthetically superior to cast metal Control over occlusal contour and vertical dimension Inferior marginal fit May be bulky Possible inadequate wear resistance for posterior use Requires at least two appointments Expensive Success rate of 96% for palatal veneers over 2 years (n=75) porcelain Best aesthetics Good abrasion resistance Well tolerated by gingival tissues Potentially abrasive to opposing teeth Brittle should be used in bulk Hard to repair expensive Multiple studies suggest a success rate in excess of 90% over 5 years+ Many of the restorations placed may actually increase the vertical dimension. Controversy exists over the risks associated with doing that. However, recently it appears that increases in the vertical dimension can be tolerated especially in young patients and a balanced occlusion is soon achieved by differential eruption of teeth.54,55,56,57,58 Long term review Regular review for patients suffering from dental erosion is recommended in order to monitor further tooth loss, maintain the exciting restorations and to provide support for the patient.
  20. 20. Case (1) Dental Erosion Literature Review Feda Zawaideh 20 CONCLUSION Early recognition of erosion is important to successfully manage and prevent disease progression. A brief review of etiologic factors has been presented and recommendations made for evaluation and management of the patient with erosion. These include a complete problem and medical history aimed at identifying possible risk factors, including those for other forms of tooth wear. This is important to determine the aetiology and help direct treatment. Specialized testing such as GERD assessment may be appropriate and necessitate referral. The management of eating disorders requires a multidisciplinary approach. Whether or not aetiology can be determined, a prevention protocol for prevention of progression of erosion should be initiated. Restorative treatment is undertaken where indicated. The patient should be monitored at regular intervals by photographs or impressions of the dentition to determine compliance and success of treatment.
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