Tooth Surface Loss Due to Dental Erosion



by Dr. Hadeel Al-Ateeqi





Abstract

Tooth Surface Loss is an increasing problem, it may results from erosion, attrition, abrasion and abfraction. It can presents due to one condition or in combination, each has its own clinical management. This paper is about tooth Surface Loss due to acid erosion. Acid erosion can be from extrinsic or intrinsic sources. The management of patients with acid erosion will be discussed.

Clinical Relevance: Initial management of patients with dental erosion is important to control further tooth surface loss that might complicate the treatment

Key Words: Acid erosion, prevention, Dahl concept


Introduction

Dental erosion is one form of tooth substance loss. It is by definition :The progressive loss of tooth substance by chemical process that do not involve bacterial action producing defects that are sharply defined, wedged shaped depressions often in facial and cervical areas. It is increasingly common condition affecting children and adults.1 A study of random sample in Switzerland from two age adult groups reported frequent to severe erosion. The adult dental health survey in 1998 stated that 65% of adults in the up had some form of toothwear.2 A study of random sample of 14 years old children in the UK reported 48% of children had low erosion, 51% had moderate erosion and 1% had severe erosion.3 The management of patients with acid erosion is based on identifying the risk factors, prevention, restorative management when indicated and monitoring its progress.


Role of acid in Dental Erosion

Tooth enamel can dissolve at a pH 5.5 or below and Dentine can dissolve at a pH of 6.5 or below.4 Table 1 showed different food and drinks and their associated pH.5 Acid weaken the outer 3-5 microns of mineralized tissue and increase the susceptibility of the enamel and dentine to abrasion from tooth brushing with or without tooth paste.

 Item                    Approximate pH  
 Lemon Juice                  2.00 - 2.60     
 Coke                                   2.60        
 Vinegar                               3.20        
 Grapes                           2.90 - 4.50      
 Apple                             3.30 - 3.90      
 Orange                           3.30 - 4.05      
 Apricots                         3.30 - 4.80    
 Red wine                             3.40        
 Salad dressing                     3.60        
 Tomatoes                        4.30 - 4.90  
 Milk                                    6.70        
Table 1: Dietary items pH


Risk Factors

There are many Factors involved that can be extrinsic and intrinsic.

Extrinsic factors
. Diet: The erosive activity of citric, malic and phosphoric presents in some food and drinks causes dental erosion. The Potential for theses acids to be erosive depends on its pH, its titrable acid content and buffering capacity. The greater the buffering capacity of the drink, the longer it will take for saliva to neutralize the acid.
. Medication: Such as Chewable Asprin tablets, Chewable Vitamin C.
. Environmental: contact with acid as part of work e.g. industrial process. Swimming in swimming pool.


Intrinsic Factors
. Vomiting: repeated induced vomiting e.g. Anorexia nervosa and Bullimia. Repeated not controlled vomiting such as in pregnancy.
. Rumination: Uncommon , it’s the ability to relax the lower esophageal sphincter, reflux gastric contents into the mouth and reswallow.
. Gastric acid Reflux: Reflux of hydrochloric acid from the stomach into the oral cavity. It can be due to incompetence of lower esophageal sphincter such as in Hiatus hernia, oesophagitis and the use of some drugs and Increased gastric volume and pressure. Gastro-esophageal reflux disease (GERD) is the passive effortless movement of regurgitated acid into the mouth. Signs and symptoms are: restrosternal discomfort, heartburn, Epigastric pain. Some patients are asymptomatic.6 There is strong association between GERD and dental erosion, the severity of dental erosion correlated with the presence of GERDS symptoms.7 


The role of Saliva in dental Erosion

Saliva flow rate and buffering capacity are the most important biological modifying factors. Salivary bicarbonate is the principal buffer in saliva, it provide some protection through acid clearance and neutralization. The buffering by saliva of dietary acids is much quicker in the erosive than in the carious process.8 Saliva provides calcium, phosphate and possibility fluoride necessary for remineralization. Salivary pellicle acts as a type of diffusion barrier that limits acid penetration and mineral ingress.


Management of patients of patients with dental Erosion

. Extra oral examination: General extra oral examination. Presence of Russells signs which is a callous formation on the back of the hand used to induce vomiting is indication of Bullimia
. Intra oral examination: Clinical signs of dental erosion can presents as listed in table 2 (Figures 1,2,3)

. Medical consultation: Communication with the patient physician if there was symptoms of GERD
. Radiographic analysis
. Intra oral photographs: for case study and monitoring
. Diet analysis: four days diet sheet including the days weekend must be completed by the patient to investigate the presence of acidic food
. Study Models: for monitoring the rate of dental erosion, should be repeated every 6-12 months. 9,10,11,12


Clinical signs of Dental erosion
Smooth Polished appearance of Teeth                     
Absence of Developmental ridges                          
Rounded teeth                                                      
Increased translucency due to thinning of enamel  
Cupping                                                                
Amalgam and composite restorations stand Proud  
Base of lesion not in contact with Opposing tooth  
.  Absence of staining                                              
Discoloration, Teeth have yellow appearance         
Table 2: Intra Oral Clinical Signs of Erosion


Figure 1: Palatal erosion in cases with gastric acid reflux
Figure 2: Cupping of lower posterior teeth
Figure 3: Severe acid erosion affecting upper anterior teeth


Prevention of Dental Erosion

1. Prevention is based on early recognition of signs and acid erosion
2. Risk assessment: Assessing the presence of any risk factors associated with dental erosions
3. Patient Education: Preventive advice should be given to patients as listed in table 3 13,14
4. Control of further tooth loss by mechanical protection of teeth such as with composite resin


Patient education  
. Personalized                                                                                   
. Active patient engagement                                                             
. Avoid swishing and holding drink in the mouth and drink with straw  
. Reduce frequency of acid intake                                                      
. Confine acid to meal time                                                               
. Where possible recommend safer alternatives food drinks                
. Follow acid intake with water                                                          
. Consider use of salivary stimulant e.g. cheese, sugar free gum  
. Brush teeth with fluoride tooth paste e.g. Pronamel tooth paste        
. Avoid brushing for one hour following acid intake                             
. Advice use of (CPP-ACP) products such as GC MI paste plus                  
. Consider use of Fluoride mouth wash                                               
Table 3: Patient Education




Treatment

Treatment is indicated when the oral environment is stable, tooth wear and disease have been controlled, the presence of symptoms, deteriorating appearance and encroachment of interarch space. Treatment of early erosive tooth wear if the spaces for restorations are available is simply by adhesive restorations. Majority of patients with acid erosion have lost the clinical crown height of their anterior teeth which allowed for dento - alveolar compensation to take place (Figure 4). The Dahl concept which was developed by Dahl in 1975 allows for creation of the space in the anterior region by allowing posterior teeth to over erupt in certain clinical situation as indicated in table 4. The original Dahl appliance was based on Metal Cobalt Chromium appliance cemented on palatal surfaces of upper anterior teeth.15, 16, 17, 18 more recently Composite restorations are used to create the space.19 The placement of Composite restorations to treat localized anterior tooth wear has good short to medium term survival.20 A survival analysis study of composite restorations to manage localized anterior tooth wear demonstrates it’s a viable treatment option over a ten year period.21 Treatment of advanced erosive tooth wear is by indirect restorations.22, 23


Figure 4: Dento - alveolar compensation in a case with severe acid erosion


Case selection for Dhal appliance
. Localized anterior tooth wear                     
. Good oral hygiene                                      
. Good periodontal health and bone support  
. Stable posterior occlusion                           
Table 4: Case selection for Dhal appliance




Conclusion

Prevention is the key to success in the management of erosive tooth surface loss just as it is in the treatment of other pathological processes such as caries and periodontal disease. Intervention in terms of preventive advice and monitoring is required in all cases where erosion is diagnosed. Adopting this approach can reduce the need for extensive treatment and contribute to improving the prognosis for any restorative treatment that is provided.


References

1. Lucci A, Schaffner M, Shutter P. Dental erosion in population of Swiss adults.
Community Dental Oral Epidemiology 1991; 19: 286-290.
2. Kelly M, Steel JG, Nuttall N. Adult dental health survey. Oral Health in the
united Kingdom, London: ONS.1998.
3. Al-Dlaigan YH, Shaw L, Smith A. Dental erosion in a group of British 14-yearold
school children. Part I: Prevalence and influence of different socioeconomic
backgrounds. British Dental Journal 2001; 190: 145-149.
4. Bartlett DA. The role of erosion in tooth wear: etiology, prevention and management.
International Dental Journal 2005; 55: 277-284.
5. Rees JS. The Role of Drinks in Tooth Surface Loss. Dental Update 2004; 31:
318-326.
6. Osullivan E, Milosevic A. UK national clinical guidelines in Peadiatric Dentistry:
diagnosis, prevention and management of dental erosion. International Journal of
Paediatric Dentistry 2008; 18:29-38.
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dental practitioner. International Dental Journal 2005; 55: 285-290.
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6-11.
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dentition. Journal of Oral Rehabilitation 2008; 35: 548-566.
13. Chander S, Rees J. Strategies for the Prevention of Erosive Tooth Surface Loss.
Dental Update .2010; 37:12-18
14. Mehta SB, Banerji S, Miller BJ, Suarez-Feilto. Current concept on the management
of tooth wear: part 1.British Dental Journal 2012;212:17-27
15. Shava S, Summerwill AJ. Reviewing the Concept of Dahl. Dental Update 2004;
31: 442-447
16. Pyster NJ, Porter RWJ, Briggs PFA, Chana HS, KELLEHER M. The Dahl Concept:
past, present and future. British Dental Journal 2005; 198: 669-676.
17. Bloom DR, Padayachy JN. Increasing occlusal vertical dimension-why, when
and how. British Dental Journal 2006;200:251-256.
18. Dahl BL, Krogstad O, Karlsen K. An alternative treatment in cases with advanced
localized attrition. J Oral Rehabil 1975;2:209-14.
19. Robinson S, Nixon P, Gahan MJ, Chan FW. Techniques for Restoring Worn
Anterior Teeth with Direct Composite Resin. Dental Update 2008; 35: 551-558.
20. Redman CDJ, Hammings KW, Good JA. The survival and clinical performance
of resin-based composite restorations used to treat localized anterior tooth wear.
British Dental Journal 2003; 194: 566-572.
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up).British dental Journal 2011;211:1-7.
22. Chadwick RG. Dental erosion. Quintessence publishing, 2006.
23. Khan F, Young WG. The ABC of the Worn Dentition. Willey- Blackwell , 2011.





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