Who Is At Risk for Acid Wear?
Sandy Nickolson, RDH, MEd, RF
A patient’s lifestyle has clear ties to his or her dental health. As dental professionals we monitor patients for oral cancer, caries, periodontal disease, and temporomandibular disorders (TMD) on a regular basis, but what about areas of erosion? Are patients only checked at their initial exam appointment and then occasionally when an area becomes sensitive? The etiology of erosion must be identified so that the clinical management of the patient—both preventive and restorative—can be undertaken. Many health-conscious patients mistakenly believe that warding off caries and perio-dontal disease is the most important thing they can do for their oral health. While that strategy is sound, we need to take a more proactive approach. There is now a new front in oral health that dental professionals can help their patients understand and manage: acid erosion and tooth wear.
Patients today are keeping their teeth longer than ever before, which raises new concerns as they age.1 Modern lifestyles present a range of challenges to teeth that were not prevalent in previous generations. Acidic diets, in particular, can take a serious toll on tooth structure, and stringent oral hygiene habits can actually contribute to the issue. Much of this information comes as a surprise for patients. However, our guidance and attention can help patients identify habits and lifestyle issues that put them at risk for erosion, helping to slow its progress and reduce the likelihood of reaching an advanced stage.
WHY EROSION? WHY NOW?
Oral health researchers project that erosion will become a demanding factor in 21st century dental practices. Over the course of a lifetime, tooth wear is a normal phenomenon, but recent trends indicate we can expect to see greater severity and more frequent cases of extreme tooth surface loss.1
A number of factors contribute to erosion, including medications, eating disorders, or environmental acids; but, as pre-viously noted, acidic foods are common culprits. The nation’s poor eating habits have been criticized in the health care community for years now, but in the case of erosion, foods deemed both healthy and unhealthy play a role. In fact, healthy foods and eating habits may be quite significant contributors to erosion. Fruits and vegetables—the building blocks of a healthy diet—often have a very low pH (high acidity). Other nutritional staples like yogurt, wine, and tea fall within an acidic range as well.2 In addition, the dietary practice of grazing (eating small meals or snacks throughout the day) can cause damage by not allowing teeth enough time to be fully remineralized by saliva between meals.
For the same reason, many everyday beverages can be highly erosive. It is not uncommon for many people to sip coffee, tea, soda, sports drinks, carbonated beverages, or even bottled water with fresh lemon or lime over the course of an hour, or worse—throughout the entire day. This prolonged “acid attack” prevents saliva from neutralizing the acidity or remineralizing enamel, a process that takes several hours.3 Because saliva is supersaturated with calcium and phosphorus, it helps inhibit demineralization of the tooth structure, therefore giving it a very important role in the management of erosion.
In its early stages, erosion can manifest subtly. However, the signs become increasingly clear as the condition progresses. Initially, as enamel wears off, the teeth may become shiny and smooth-looking, and then later develop a dull appearance. As enamel continues to thin, teeth may appear yellow due to the underlying dentin showing through. Next in the progression, incisors may display an increased translucency as incisal edges become thinner. After these stages, the structure and form of teeth may be irreversibly damaged, progressing from small cracks and fractures to notch-shaped spaces, cupping, and cratering.
An additional complication that can result from erosion is dentin hypersensitivity. As enamel is worn away from the teeth, areas of dentin may be left exposed
and more vulnerable to painful sensitivity.1 Patients who present with sensitivity should not only be informed of the possible link between their diet and their tooth pain, but should also work with the dental professional to create a dietary analysis. Often a dietary history can be very revealing.
Early diagnosis is important, so as dental professionals we must remember that all patients are at risk for tooth wear.4 Look for signs of erosion during each exam, and question each patient about dentin hypersensitivity, as this may indicate erosion as well. Radical dietary changes are often not sustainable for patients, but you can en-gage in a dialogue with them about habits they might slowly adapt. A number of achievable small changes can add up to an appreciable difference.
Erosion cannot be reversed, but preventive measures can be taken to slow or halt further progression by dietary adjustments and changes to the oral health regimen. Because acquired pellicle provides protection against erosion, patients should be instructed not to brush their teeth for at least 1 hour after an erosive challenge (such as consumption of a highly acidic beverage)1 and also to use a soft toothbrush with a low-abrasion, pH-neutral toothpaste. Using a toothpaste that offers high fluoride uptake, such as Sensodyne® Pronamel (GlaxoSmithKline, Research Triangle Park, NC), can be beneficial as well, because the fluoride helps to reharden softened enamel.1 Pronamel has the additional feature of 5% potassium nitrate, which can help relieve the dentin hypersensitivity caused by worn enamel. Regular dental treatment and the use of dental products containing fluorides and the avoidance of low-pH products can all be beneficial in the treatment and management of erosion and the hypersensitivity that patients experience.
No one is immune to erosion, but education and heightened awareness can help patients prevent serious damage as they age. While erosion can take years to accumulate to the point where restorative treatment is indicated, proactive patients can begin defending their teeth from erosion right away. Our assistance and counsel in this matter can help patients maintain their healthiest smiles and optimum dental health for decades to come.
References1. Zero DT, Lussi A. Erosion—chemical and biological factors of importance to the dental practitioner. Int Dent J. 2005;55(4 Suppl 1): 285-290.
2. Gandara BK, Truelove EL. Diagnosis and management of dental erosion. J Contemp Dent Prac. 1999;1(1):16-23.
3. Barbour ME, Rees GD. The role of erosion, abrasion and attrition in tooth wear. J Clin Dent. 2006;17(4):88-98.
4. Bartlett DW. The role of erosion in tooth wear: aetiology, prevention and management. Int Dent J. 2005;55(4 Suppl 1):277-284.
Sandy Nickolson, RDH, MEd, RF