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Acid erosion is a type of
tooth wear Tooth wear refers to loss of tooth substance by means other than dental caries. Tooth wear is a very common condition that occurs in approximately 97% of the population. This is a normal physiological process occurring throughout life; but with in ...
. It is defined as the irreversible loss of tooth structure due to chemical dissolution by acids not of
bacteria Bacteria (; singular: bacterium) are ubiquitous, mostly free-living organisms often consisting of one biological cell. They constitute a large domain of prokaryotic microorganisms. Typically a few micrometres in length, bacteria were among ...
l origin. Dental erosion is the most common chronic condition of children ages 5–17, although it is only relatively recently that it has been recognised as a dental health problem. There is generally widespread ignorance of the damaging effects of acid erosion; this is particularly the case with erosion due to consumption of fruit juices because they tend to be considered as healthy. Acid erosion begins initially in the enamel, causing it to become thin, and can progress into
dentin Dentin () (American English) or dentine ( or ) (British English) ( la, substantia eburnea) is a calcified tissue of the body and, along with enamel, cementum, and pulp, is one of the four major components of teeth. It is usually covered by ena ...
, giving the tooth a dull yellow appearance and leading to
dentin hypersensitivity Dentin hypersensitivity (DH, DHS) is dental pain which is sharp in character and of short duration, arising from exposed dentin surfaces in response to stimuli, typically thermal, evaporative, tactile, osmotic, chemical or electrical; and which ca ...
. The most common cause of erosion is by acidic foods and drinks. In general, foods and drinks with a pH below 5.0–5.7 have been known to trigger dental erosion effects. Numerous clinical and laboratory reports link erosion to excessive consumption of such drinks. Those thought to pose a risk are soft drinks, some alcohol and fruit drinks, fruit juices such as
orange juice Orange juice is a liquid extract of the orange (fruit), orange tree fruit, produced by squeezing or reaming oranges. It comes in several different varieties, including blood orange, navel oranges, valencia orange, clementine, and tangerine. A ...
(which contain
citric acid Citric acid is an organic compound with the chemical formula HOC(CO2H)(CH2CO2H)2. It is a colorless weak organic acid. It occurs naturally in citrus fruits. In biochemistry, it is an intermediate in the citric acid cycle, which occurs in t ...
) and
carbonated drinks A soft drink (see § Terminology for other names) is a drink that usually contains water (often carbonated), a sweetener, and a natural and/or artificial flavoring. The sweetener may be a sugar, high-fructose corn syrup, fruit juice, a su ...
such as
cola Cola is a carbonated soft drink flavored with vanilla, cinnamon, citrus oils and other flavorings. Cola became popular worldwide after the American pharmacist John Stith Pemberton invented Coca-Cola, a trademarked brand, in 1886, which was imita ...
s (in which the carbonic acid is not the cause of erosion, but citric and
phosphoric acid Phosphoric acid (orthophosphoric acid, monophosphoric acid or phosphoric(V) acid) is a colorless, odorless phosphorus-containing solid, and inorganic compound with the chemical formula . It is commonly encountered as an 85% aqueous solution, w ...
). Additionally,
wine Wine is an alcoholic drink typically made from fermented grapes. Yeast consumes the sugar in the grapes and converts it to ethanol and carbon dioxide, releasing heat in the process. Different varieties of grapes and strains of yeasts are m ...
has been shown to erode teeth, with the pH of wine as low as 3.0–3.8. Other possible sources of erosive acids are from exposure to poorly regulated
chlorinated In chemistry, halogenation is a chemical reaction that entails the introduction of one or more halogens into a compound. Halide-containing compounds are pervasive, making this type of transformation important, e.g. in the production of polymers, ...
swimming pool A swimming pool, swimming bath, wading pool, paddling pool, or simply pool, is a structure designed to hold water to enable Human swimming, swimming or other leisure activities. Pools can be built into the ground (in-ground pools) or built ...
water, and regurgitation of
gastric acid Gastric acid, gastric juice, or stomach acid is a digestive fluid formed within the stomach lining. With a pH between 1 and 3, gastric acid plays a key role in digestion of proteins by activating digestive enzymes, which together break down the ...
s. In children with chronic diseases, the use of medicines with acid components is a risk factor too. Dental erosion has also been recorded in the fossil record and was likely caused by the consumption of acidic fruits or plants.


Causes


Extrinsic acidic sources

Extrinsic acid erosion is when the source of acid originates from outside of the body. Acidic food and drink lowers the pH level of the mouth resulting in demineralisation of the teeth. A variety of drinks contribute to dental erosion due to their low pH level. Examples include
fruit juices Juice is a drink made from the extraction or pressing of the natural liquid contained in fruit and vegetables. It can also refer to liquids that are flavored with concentrate or other biological food sources, such as meat or seafood, such as ...
, such as apple and orange juices, sports drinks,
wine Wine is an alcoholic drink typically made from fermented grapes. Yeast consumes the sugar in the grapes and converts it to ethanol and carbon dioxide, releasing heat in the process. Different varieties of grapes and strains of yeasts are m ...
and
beer Beer is one of the oldest and the most widely consumed type of alcoholic drink in the world, and the third most popular drink overall after water and tea. It is produced by the brewing and fermentation of starches, mainly derived from ce ...
. Carbonated drinks, such as colas and lemonades, are also very acidic and hence have significant erosive potential. Foods such as fresh fruits, ketchup and pickled food in vinegar have been implicated in causing acid erosion. Frequency rather than total intake of acidic juices is seen as the greater factor in dental erosion; infants using feeding bottles containing fruit juices (especially when used as a comforter) are therefore at greater risk of acid erosion.
Saliva Saliva (commonly referred to as spit) is an extracellular fluid produced and secreted by salivary glands in the mouth. In humans, saliva is around 99% water, plus electrolytes, mucus, white blood cells, epithelial cells (from which DNA can be ...
acts as a buffer, regulating the pH when acidic drinks are ingested. Drinks vary in their resistance to the buffering effect of saliva. Studies show that fruit juices are the most resistant to saliva's buffering effect, followed by, in order: fruit-based carbonated drinks and flavoured mineral waters, non-fruit-based carbonated drinks, sparkling mineral waters;
mineral water Mineral water is water from a mineral spring that contains various minerals, such as salts and sulfur compounds. Mineral water may usually be still or sparkling (carbonated/effervescent) according to the presence or absence of added gases. Tra ...
being the least resistant. Because of this, fruit juices in particular, may prolong the drop in pH levels. A number of medications such as chewable vitamin C, aspirin and some iron preparations are acidic and may contribute towards acid erosion. Certain drugs can cause hyposalivation (low quantity or quality of saliva) which is considered a risk factor for acid erosion.


Intrinsic acidic sources

Intrinsic dental erosion, also known as perimolysis, is the process whereby
gastric acid Gastric acid, gastric juice, or stomach acid is a digestive fluid formed within the stomach lining. With a pH between 1 and 3, gastric acid plays a key role in digestion of proteins by activating digestive enzymes, which together break down the ...
from the stomach comes into contact with the teeth. This is often secondary to conditions such as
anorexia nervosa Anorexia nervosa, often referred to simply as anorexia, is an eating disorder characterized by low weight, food restriction, body image disturbance, fear of gaining weight, and an overpowering desire to be thin. ''Anorexia'' is a term of Gr ...
,
bulimia nervosa Bulimia nervosa, also known as simply bulimia, is an eating disorder characterized by binge eating followed by purging or fasting, and excessive concern with body shape and weight. The aim of this activity is to expel the body of calories eate ...
,
gastroesophageal reflux disease Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is one of the upper gastrointestinal chronic diseases where stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/ ...
(GERD) and
rumination syndrome Rumination syndrome, or merycism, is a chronic motility disorder characterized by effortless regurgitation of most meals following consumption, due to the involuntary contraction of the muscles around the abdomen. There is no retching, nausea, he ...
. Dental erosion can also occur by non-extrinsic factors. There is evidence linking eating disorders with a range of oral health problems including dental erosion,
caries Tooth decay, also known as cavities or caries, is the breakdown of teeth due to acids produced by bacteria. The cavities may be a number of different colors from yellow to black. Symptoms may include pain and difficulty with eating. Complicatio ...
and
xerostomia Xerostomia, also known as dry mouth, is dryness in the mouth, which may be associated with a change in the composition of saliva, or reduced salivary flow, or have no identifiable cause. This symptom is very common and is often seen as a side ef ...
. Reduced salivary flow rate, a common symptom of bulimia, predisposes an individual to dental erosion due to increased vulnerability to the effects of acidic food and drinks. Self-induced vomiting increases the risk of dental erosion by a factor of 5.5 compared to healthy controls. Lesions are most commonly found on the palatal surfaces of the teeth, followed by the occlusal and then the buccal surfaces. The main cause of GERD is increased acid production by the stomach. This is not exclusive to adults, as GERD and other gastrointestinal disorders may cause dental erosions in children.


Behaviour

Acid erosion often coexists with abrasion and
attrition Attrition may refer to *Attrition warfare, the military strategy of wearing down the enemy by continual losses in personnel and material **War of Attrition, fought between Egypt and Israel from 1968 to 1970 **War of attrition (game), a model of agg ...
. Abrasion is most often caused by brushing teeth too hard. Any frothing or swishing acidic drinks around the mouth before swallowing increases the risk of widespread acid erosion. Sucking citrus fruits can also contribute to acid erosion.


Diagnosis

In-vivo Studies that are ''in vivo'' (Latin for "within the living"; often not italicized in English) are those in which the effects of various biological entities are tested on whole, living organisms or cells, usually animals, including humans, and pl ...
studies are advantageous in assessing erosion directly from the patient's mouth. There are numerous signs of dental erosion, including changes in appearance and sensitivity.


Color

One of the physical changes can be the color of teeth. Dental erosion can lead to two major tooth colour change - the first being a change of color that usually happens on the cutting edge of the central incisors. This causes the cutting edge of the tooth to become transparent. A second sign is a yellowish tint on the eroded tooth. This occurs because the white enamel has eroded away to reveal the yellowish dentin beneath. On top of clinical examination, the dentist may take intra-oral photographs to monitor the extent and progress of erosion. Clinical photographs lead to comparable results to a visual examination, however both may result in an underestimation of the extent of tooth wear.


Shape

A change in shape of the teeth is also a sign of dental erosion. Teeth will begin to appear with a broad rounded concavity, and the gaps between teeth will become larger. There can be evidence of wear on surfaces of teeth not expected to be in contact with one another. If dental erosion occurs in children, a loss of enamel surface characteristics can occur.
Amalgam Amalgam most commonly refers to: * Amalgam (chemistry), mercury alloy * Amalgam (dentistry), material of silver tooth fillings ** Bonded amalgam, used in dentistry Amalgam may also refer to: * Amalgam Comics, a publisher * Amalgam Digital ...
restorations in the mouth may be clean and non-tarnished. As tooth substance around restorations erodes away, fillings may also appear to be rising out of the tooth. The teeth may form divots on the chewing surfaces when dental erosion is occurring. This mainly happens on the first, second, and third molars. To monitor the change in shape over time, dentists can create and retain accurate, serial study casts. Dentists may also employ
dental indices Tooth wear refers to loss of tooth substance by means other than dental caries. Tooth wear is a very common condition that occurs in approximately 97% of the population. This is a normal physiological process occurring throughout life; but with i ...
to guide their diagnosis and management of the condition. A scoring system referred to as Basic Erosive Wear Examination (BEWE) grades the appearance or severity of wear on the teeth by the extent of hard tissue loss. It is noted that indices are useful in monitoring the most severe clinical changes in tooth wear. However, they lack comprehensiveness as they cannot measure the rate of progression and cannot monitor all teeth affected by erosion. There is also a lack of an index which is universally accepted and standardised. One of the most severe signs of dental erosion is cracking, where teeth begin to crack off and become coarse. Other signs include pain when eating hot, cold, or sweet foods. This pain is due to the enamel having been eroded away, exposing the sensitive dentin.


Optical properties

Based on the optical changes induced in eroded tissue by the lesions, in 2015 Koshoji ''et al.'' also demonstrated in a novel method that by using laser speckle images (LSI) it is possible to acquire information on the microstructure of the enamel and detect minimal changes, such as early non-carious lesions. No clinical data has been published to demonstrate the effectiveness of this technique in vivo.


Prevention and management

The causes of dental erosion are classified into two main categories – intrinsic and extrinsic. The former is due to regurgitated gastric acid from the stomach while the latter is from dietary, medicinal, occupational & recreational origins. It is important to recognise it early, detect its cause and provide relevant advice or treatment to stop its progression. Strategies for prevention and management consist of the following: Where intrinsic sources of acid have been identified: A: Individuals * Consult a medical doctor immediately if you notice or are aware of any signs and symptoms of gastroesophageal reflux disease (GERD), such as acid reflux and heartburn, or if you suffer from an eating disorder or chronic alcoholism. They can confirm the diagnosis and develop a treatment plan accordingly. * Be cautious when purchasing the following items: vitamin C, iron-tonic and amino-acid tablets, aspirin, hydrogen chloride-based preparations, asthma medications, mouthrinses with low pH, paediatric syrup medication, acidic salivary substitutes and bleaching agents. They can potentially lead to erosion. B: Dental professionals * Prescribe or administer a neutralising agent, such as antacid tablets in suspension. Antacids helps neutralise stomach acidity and inhibit proteolytic activity of pepsin, both of which provide relief to symptoms of GERD such as heartburn. Note that antacids may interfere with other medications and are not suitable for women who are pregnant or breastfeeding, those that suffer from liver disease, kidney disease or heart failure and an illness associated with sodium control, such as high blood pressure or cirrhosis. * Encourage patients to maintain their body mass index (BMI) within normal range or by making healthy lifestyle changes in relation to diet and exercise. Obesity is said to be an important risk factor in the development and deterioration of GERD. * Find out if the patient has any underlying medical conditions or did consider a change of medications that induce hyposalivation and vomiting. If the patient displays severe signs or symptoms, referral to a medical doctor is necessary. Refer patients to a dietician for them to receive personalised dietary counselling if signs and symptoms still persist. * Request that patients complete the SCOFF questionnaire, a valid and reliable screening tool for early detection and treatment of suspected eating disorders. A response of ‘yes’ receives 1 point. An accumulative score of > 2 indicates the likelihood of anorexia or bulimia. The acronym SCOFF dictates the following questions: # Do you make yourself SICK because you feel uncomfortably full? # Do you worry you have lost CONTROL over how much you eat? # Have you recently lost more than ONE stone in a 3-month period? # Do you believe yourself to be FAT when others say you are too thin? # Would you say that FOOD dominates your life? C: Industry * Develop effective over-the-counter medications for gastroesophageal reflux disease (GERD) that minimise side effects of those presently available. For instance, some side effects antacids, H2 blockers and proton pump inhibitors have in common are constipation, diarrhea and nausea. Where Extrinsic sources of acids have been identified A: Individuals * Reduce the frequency of acidic food intake, particularly carbonated (fizzy) drinks and fruit juices that contain phosphoric or citric acid. Tooth enamel and dentine are both made up of calcium deficient carbonated hydroxyapatite. Acid and/or chelators present in the food humans consume penetrate through the dental plague, the pellicle and the protein/ lipid coating into the individual crystals. Hydrogen ions combine with carbonate and/ or phosphate, releasing all ions in the affected region, giving rise to direct surface etching/ erosion. Reducing the frequency of intake, minimises the duration to which enamel is exposed to acids, making it less susceptible to acid attack and allows the eroded tooth surface to remineralise. Ideally, confine these items exclusively to mealtime. * Consume food items enriched with calcium or stimulates the flow of saliva. For instance, dairy products such as milk & cheese. Saliva acts as a buffer which resists abrupt changes in pH in the mouth and keeps it neutral. Moreover, it aids the precipitation of calcium phosphate under specific pH conditions and bathes the tooth surface in fluoride, both of which promote remineralisation. * Drink through a straw to reduce localised contact between erosive fluids and the teeth. Similarly, drinks should not be held in the mouth or sipped for a long period of time. Otherwise, rinse your mouth thoroughly with water or chew sugar-free gum immediately after as it removes residual food debris and lowers the pH of saliva. The result of salivary flow rate and salivary pH from chewing gum for 20 minutes is significantly greater than resting flow rate. * Avoid abrasive forces by brushing gently using a soft bristled hand toothbrush. In-vitro research has shown that there is a higher potential for abrasion on erosive enamel & dentine with an electric toothbrush as compared to a manual toothbrush. Furthermore, delay brushing of teeth until approximately an hour after an acidic meal to prevent the removal of softened tooth substance. * Use products that promote remineralisation such as fluoride-containing mouthrinses and toothpastes. Fluoride-containing products promote repair of acid damaged tooth surfaces and block exposed dentine tubules, reducing dentine permeability and preventing hypersensitivity. When used before contact with acid, fluoride-containing products also help inhibit acid erosion.
Stannous fluoride Tin(II) fluoride, commonly referred to commercially as stannous fluoride (from Latin ', 'tin'), is a chemical compound with the formula SnF2. It is a colourless solid used as an ingredient in toothpastes. Oral health benefits Stannous fluoride wa ...
(SnF2)-containing toothpastes in particular have been shown to increase resistance to acid erosion compared to other fluoride-containing toothpastes. B: Dental professionals * To facilitate detection and diagnosis, dental professionals should be aware of the appearance of tooth erosion – short, cupped, saucer-shaped with a glassy, shiny surface and loss of surface architecture. Several teeth are affected at the same time, with the most commonly affected area being the tongue surfaces of the upper front teeth. * Recording index. Use the Basic Erosive Wear Examination (BEWE), an objective four-level scoring system to determine the severity of erosion in each sextant. The cumulative score corresponds to its level of risk and acts as a guide for appropriate management. The distribution of BEWE scores is said to be more accurate than that of Tooth wear index (TWI) scores. ** 0 = no erosive tooth wear ** 1 = initial loss of surface texture ** 2 = distinct defect, hard tissue loss < 50% of surface area ** 3 = hard tissue loss ≥ 50% of surface area * Minimal intervention & prevention of dental erosion. The first line treatment after detection of acid erosion is remineralisation and prevention. Remineralisation is the reparative process of demineralised tooth substance. It is commonly promoted by applying fluoride-containing substances onto the surfaces of affected teeth, though is limited by bioavailable calcium. The following are some methods of remineralisation: professionally-applied fluoride varnish, home-applied fluoride gel and toothpaste with stannous fluoride (SnF2) formulation. Prevention of erosion is largely through discussions regarding avoidance/management of extrinsic and intrinsic sources of acid, and recommendation of suitable at-home preventive oral hygiene habits. Correct tooth brushing technique (timing, bristle stiffness, brushing force & toothpaste) should be discussed. Toothpastes containing stabilized stannous fluoride have higher anti-erosive properties when compared to conventional sodium fluoride or sodium monofluorophosphate formulations. Where possible, a stabilized stannous fluoride-containing toothpaste should be recommended. * Restoration is the process of building back lost tooth structure to restore their function, integrity and morphology. The type of restorative treatment depends on the degree of damage that has been done: # Small area of erosion along the biting surfaces of tooth can be restored using detection of acid erosion is resin composite filling. This is a tooth-coloured filling material commonly used to restore decayed teeth. # Moderate degree of damage at upper from teeth can be restored using detection of acid erosion is ceramic or resin composite veneers. A veneer is a thin piece of tooth-coloured, custom-made shells that cover the front side of teeth. # Large extent of damage, involving two or more surfaces of tooth can be restored using ceramic crowns or overlays. Crowns are tooth-shaped capsplaced over the damaged tooth to restore its shape; Overlays are pre-built fillings that are used to rebuild the pointed parts of back teeth (known as cusps). However, long-term treatment success is only possible when the causes of acid erosion are eradicated. Otherwise, the erosive process will continue to destroy tooth substance. To achieve best outcomes, combining active treatment with preventive measures and recall at regular periods is needed. C: Industry * Avoid having environments where there is repeated exposure and inhalation of acidic particles in occupational areas when possible as several case reports have proven a link between this and the prevalence of dental erosion. Alternatively, subsidise regular dental services for those with higher risk of developing the condition. For instance, professional wine tasters, competitive swimmers and industrial workers working in factories that involve batteries, galvanizing or ammunition. * Educate workers on potential occupational hazards and promote maintenance of good oral health. For instance, standardise behaviours such as wearing personal protective equipment for the eyes and face and gargling during or after working. * Alter pH or chelation properties of acidic soft drinks, particularly those with citric or phosphoric acid by reducing its composition. Tooth enamel is composed of calcium-deficient carbonated hydroxyapatite. Chelating agents like hydrogen or citrate ions combine with calcium, carbonate or phosphate ions in the region, thereby causing direct surface etching and tissue loss.


See also

*
Tooth wear Tooth wear refers to loss of tooth substance by means other than dental caries. Tooth wear is a very common condition that occurs in approximately 97% of the population. This is a normal physiological process occurring throughout life; but with in ...
* Abrasion *
Abfraction Abfraction is a theoretical concept explaining a loss of tooth structure not caused by tooth decay (non-carious cervical lesions). It is suggested that these lesions are caused by forces placed on the teeth during biting, eating, chewing and grin ...
*
Attrition Attrition may refer to *Attrition warfare, the military strategy of wearing down the enemy by continual losses in personnel and material **War of Attrition, fought between Egypt and Israel from 1968 to 1970 **War of attrition (game), a model of agg ...
*
Bruxism Bruxism is excessive teeth grinding or jaw clenching. It is an oral parafunctional activity; i.e., it is unrelated to normal function such as eating or talking. Bruxism is a common behavior; reports of prevalence range from 8% to 31% in the gene ...
* Stephan curve


References


External links


Saliva and Tooth Dissolution
{{Authority control Acquired tooth pathology