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
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.
|Lemon Juice||2.00 – 2.60 pH|
|Grapes||2.90 – 4.50|
|Apple||3.30 – 3.90|
|Orange||3.30 – 4.05|
|Apricots||3.30 – 4.80|
|Tomatoes||4.30 – 4.90|
Table 1: Dietary items pH
There are many Factors involved that can be extrinsic and intrinsic.
. 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.
. 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|
|. 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
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
|. 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|
|. Discoloration, Teeth have yellow appearance|
|. 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 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
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
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.
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by Dr. Hadeel Al-Ateeqi