Oral Health Topics
- Erosion is the loss or wear of dental hard tissue by acids not caused by bacteria.
- Erosion may be caused by intrinsic (e.g., excessive vomiting or acid reflux) and/or extrinsic (e.g., diet) factors.
- Soft drinks, particularly carbonated sodas and sports drinks, appear to be the most significant extrinsic cause of erosion.
- Drinks containing high concentrations of calcium, like milk, may reduce risk of erosion.
Prepared by: Center for Scientific Information, ADA Science Institute
Dental erosion has been defined as the irreversible loss of dental hard tissue from acids, without the involvement of bacteria.1-4 The critical pH of dental enamel, made up of carbonated calcium hydroxyapatite, has been estimated as 5.5, and normally is kept in balance by saliva, which not only contains buffers to neutralize acids, but also contributes phosphate and calcium ions to aid in remineralization.5, 6
Etiology is multifactorial and can be from intrinsic (often due to recurrent vomiting) or extrinsic sources (diet, particularly soft drinks; and industrial or environmental chemicals).2, 3, 7 Beyond aesthetic consequences and associated oral health issues, erosive activity leading to exposure of the dentin can result in hypersensitivity and eventual loss of affected teeth.5, 8, 9
Prevalence is understudied but rates in various countries have been reported from 5% to 97%.10 A 2012 study of Greek adults found a prevalence rate of 28.6% among 840 individuals aged 18 to 30 years,10 and a more recent meta-analysis (2015)11 showed 34.1% of 16,661 children and adolescents worldwide exhibited dental erosion.
Intrinsic erosion results from the introduction of gastric acids into the oral cavity at a frequency exceeding the ability of the buffering capacity of saliva or other oral health measures to prevent it, usually several times a week for a number of years.7, 11
Stomach acids may reach the oral cavity at such frequencies by gastroesophageal reflux disorder (GERD) as well as recurrent vomiting, such as occurs in bulimia, chronic alcoholism, and pregnancy, when it is referred to as hyperemesis gravidarum.1, 3, 7, 12
- Gastroesophageal reflux. The regurgitation of stomach acids following meals, especially after overeating, is considered normal7, 11 for up to about 1 hour a day.3 However, in people with GERD, the intrusion of gastric acids into the oral cavity during sleep is especially damaging to the teeth, as salivation and swallowing are reduced, and, in a supine position, the lower molars can be bathed in the acids.3 Increases in intra-abdominal pressure (i.e., from obesity or pregnancy) may also increase reflux,7 and GERD has been noted as a common comorbidity of several chromic respiratory conditions.13-15
- Bulimia. Bulimia nervosa is an eating disorder that is characterized by intentional vomiting as a means to maintain a desired weight.3, 7, 16 It is a relatively common disorder among women in Western industrialized nations, with a prevalence of approximately 5% in 18-35 year old females.7 Among individuals with bulimia, the prevalence of erosion has been reported to be over 90%.7 Because patients with bulimia are generally of average weight, dentists are often the first to recognize the condition by the characteristic erosion of the lingual-palatal aspect of the anterior maxillary teeth (i.e., perimolysis or perimylolysis, see photos below),3, 7 caused by the forceful expulsion of stomach acids onto the front teeth during vomiting.
- Bulimia is contrasted with anorexia nervosa, in which weight gain is controlled by excessive restriction of diet,17 and non-purging bulimia which is characterized by periods of fasting and excessive exercise.
Photos courtesy of Craig Mabrito, D.D.S.
- Chronic Alcoholism. Alcoholism, with a prevalence of around 10% in Western countries,7 can result in erosion due to frequent vomiting and/or increased regurgitation.7, 18 Erosion in individuals with alcoholism can also be exacerbated by the consumption of acidic drinks.5, 12 In one study, erosion was found in 92% of 37 patients with alcoholism,7 and in a more recent study,18 49.4% of the teeth of 50 individuals with alcoholism were found to show signs of erosion.18 As in bulimia, the palatal surfaces of the anterior maxillary teeth tend to be the most affected, but erosion advances are more common to the occlusal and palatal surfaces of the posterior, and incisal edges of the anterior, maxillary dentition.7, 18
- Pregnancy. The increase in intra-abdominal pressure during pregnancy may result in an increase in reflux, but dental erosion is rare unless vomiting is chronic, as in the case of hyperemesis gravidarum.7
Unlike intrinsic factors for dental erosion, erosion due to extrinsic factors may be a modern phenomenon,3, 19
even increasing after the introduction of diet sodas.3
Extrinsic causes are dietary, lifestyle, environmental or occupational factors that erode dental hard tissue by contact with acids in beverages2, 3, 5
or inorganic acid vapors released into the environment.2, 5
- Beverages. Arguably the most significant cause of extrinsic dental erosion1, 3, 11 are soft drinks and fruit juices which have low pH values (2.0-3.5).3, 4 Any beverage with a low pH is a risk for erosion,3 especially with frequent consumption.3, 4, 12, 20, 21 Wine, for example, is rarely noted as a cause for erosion because it is rarely consumed as frequently as sports drinks and diet sodas.4 In 2016, a paper by Reddy et al.22 in JADA included measured pH for commercially available beverages available in the U.S. Of the 379 beverages analyzed, 93% had a pH of less than 4.0.22
A number of recent studies11, 12, 19, 23 support the hypothesis that dietary acids are a major contributing factor in dental erosion.7, 24 A 2012 meta-analysis found a more than double the risk of erosion from soft drinks as well as an increase in risk from chewable vitamin C tablets.23 Many studies, including a 2015 meta-analysis, find that natural fruit juices as well as carbonated soft drinks and acidic, sweet snacks to be significant erosion risk factors.11
- Lifestyle. More frequent consumption of highly acidic fruit and sport drinks in combination with decreases of salivary flow and dehydration from athletic or strenuous activity may increase erosion risk.2 Intense workouts may also increase the possibility of gastroesophageal reflux.2 There is some evidence that a vegetarian diet can lead to increased erosion.25, 26
- Industrial and Occupational Risks. Airborne industrial acids have been implicated in dental erosion among factory workers,1, 2 particularly in munitions, battery, and fertilizer plants.2 Swimmers frequenting poorly monitored chlorinated swimming pools have been reported to have increased levels of erosion, due to lowering of the water’s pH balance.1, 2, 5
Prevention and Management
Since dental erosion is irreversible, the focus of erosion intervention is prevention and reduction, followed by management.12
Most studies find that milk and yogurt products (presumably unsweetened) can have a protective effect on erosion11, 12, 23 because of their calcium and phosphate content. Calcium supplemented to acidic beverages, and other calcium-enriched products, have been suggested but not well studied as to their efficacy.12 Fluoride may contribute to remineralization of enamel,6, 8 but others have warned that fluoride’s “ability to prevent erosion cannot be presumed.”2
More recently, however, several in situ studies27-33 have indicated that fluoride treatments are effective in protecting dental enamel from the effects of erosion, although efficacy varies according to compound or preparation, and further research is needed.
- Avoid acidic beverages, particularly swishing or holding the liquid in the mouth.2, 12 Use of a straw, palatally, is recommended to avoid bathing the teeth (placing the straw in front of the teeth increases erosion).12
- Drink water, or preferably milk, while eating, or rinse the mouth following meals or consuming acidic drinks.3, 23
- After vomiting, rinse the mouth with milk or water.3, 23
- Saliva helps buffer and remove acids; chewing gum may help protect teeth from erosion by promoting saliva flow.
- Drink milk along with acidic meals or beverages, which contributes to remineralization and helps neutralize acids.
- Avoid brushing teeth immediately after eating or drinking acidic beverages.3, 11, 34 Wait at least one hour after eating, drinking, or vomiting.3, 35
- Brush teeth using a soft bristle brush and fluoride toothpaste.34 Look for products that carry the ADA Seal of Acceptance.
ADA Seal of Acceptance
Look for the ADA Seal—your assurance that the product has been objectively evaluated for safety and efficacy by an independent body of scientific experts, the ADA Council on Scientific Affairs. A company earns the ADA Seal for a product to help prevent or reduce enamel erosion from dietary acids by providing scientific evidence demonstrating the safety and efficacy of its product, which is evaluated according to the objective requirements related to their claims.
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- Zero DT. Etiology of dental erosion--extrinsic factors. Eur J Oral Sci 1996;104(2 ( Pt 2)):162-77.
- Schlossman M, Montana M. Preventing Damage to Oral Hard and Soft Tissues. In: Spolarich AE, Panagakos FS, editors. Prevention Across the Lifespan: A Review of Evidence-Based Interventions for Common Oral Conditions. Charlotte: Professional Audience Communications, Inc.; 2017. p. 97-120.
- Mandel L. Dental erosion due to wine consumption. The Journal of the American Dental Association 2005;136(1):71-75.
- Meurman JH, ten Cate JM. Pathogenesis and modifying factors of dental erosion. Eur J Oral Sci 1996;104(2 ( Pt 2)):199-206.
- Featherstone JDB. THE SCIENCE AND PRACTICE OF CARIES PREVENTION. The Journal of the American Dental Association;131(7):887-99.
- Scheutzel P. Etiology of dental erosion--intrinsic factors. Eur J Oral Sci 1996;104(2 ( Pt 2)):178-90.
- Twetman S. The evidence base for professional and self-care prevention-caries, erosion and sensitivity. BMC oral health 2015;15(1):S4.
- ten Cate J, Imfeld T. Dental erosion, summary. European Journal of Oral Sciences 1996;104(2):241-44.
- Chrysanthakopoulos NA. Prevalence and Associated Factors of Dental Erosion in a Population of Greek Adults. Acta Stomatologica Croatica 2012;46(4).
- Salas MM, Nascimento GG, Vargas-Ferreira F, et al. Diet influenced tooth erosion prevalence in children and adolescents: Results of a meta-analysis and meta-regression. J Dent 2015;43(8):865-75.
- Lussi A, Schlueter N, Schmalz G, et al. Consensus Report of the European Federation of Conservative Dentistry. Clinical Oral Investigations 2015;19(7):1557-61.
- Cazzola M, Segreti A, Calzetta L, Rogliani P. Comorbidities of asthma: current knowledge and future research needs. Curr Opin Pulm Med 2013;19(1):36-41.
- Lee AL, Goldstein RS. Gastroesophageal reflux disease in COPD: links and risks. Int J Chron Obstruct Pulmon Dis 2015;10:1935-49.
- Raghu G, Amatto VC, Behr J, Stowasser S. Comorbidities in idiopathic pulmonary fibrosis patients: a systematic literature review. Eur Respir J 2015;46(4):1113-30.
- Hellstrom I. Oral complications in anorexia nervosa. Scand J Dent Res 1977;85(1):71-86.
- Scheutzel P. Etiology of dental erosion – intrinsic factors. European Journal of Oral Sciences 1996;104(2):178-90.
- Manarte P, Manso MC, Souza D, Frias-Bulhosa J, Gago S. Dental erosion in alcoholic patients under addiction rehabilitation therapy. Med Oral Patol Oral Cir Bucal 2009;14(8):e376-83.
- Huysmans MC, Chew HP, Ellwood RP. Clinical studies of dental erosion and erosive wear. Caries Res 2011;45 Suppl 1(Suppl. 1):60-8.
- Imfeld T. Dental erosion. Definition, classification and links. European journal of oral sciences 1996;104(2):151-55.
- Meurman JH, Vesterinen M. Wine, alcohol, and oral health, with special emphasis on dental erosion. Quintessence Int 2000;31(10):729-33.
- Reddy A, Norris DF, Momeni SS, Waldo B, Ruby JD. The pH of beverages in the United States. J Am Dent Assoc 2016;147(4):255-63.
- Li H, Zou Y, Ding G. Dietary factors associated with dental erosion: a meta-analysis. PLoS One 2012;7(8):e42626.
- Zipkin I, McClure F. Salivary citrate and dental erosion: procedure for determining citric acid in saliva-dental erosion and citric acid in saliva. J Dent Res 1949;28(6):613-26.
- Linkosalo E, Markkanen H. Dental erosions in relation to lactovegetarian diet. Scand J Dent Res 1985;93(5):436-41.
- Staufenbiel I, Weinspach K, Forster G, Geurtsen W, Gunay H. Periodontal conditions in vegetarians: a clinical study. Eur J Clin Nutr 2013;67(8):836-40.
- West N, Seong J, Macdonald E, et al. A randomised clinical study to measure the anti-erosion benefits of a stannous-containing sodium fluoride dentifrice. J Indian Soc Periodontol 2015;19(2):182-7.
- Bellamy PG, Harris R, Date RF, et al. In situ clinical evaluation of a stabilised, stannous fluoride dentifrice. Int Dent J 2014;64 Suppl 1:43-50.
- Hooper S, Seong J, Macdonald E, et al. A randomised in situ trial, measuring the anti-erosive properties of a stannous-containing sodium fluoride dentifrice compared with a sodium fluoride/potassium nitrate dentifrice. Int Dent J 2014;64 Suppl 1:35-42.
- Eversole SL, Saunders-Burkhardt K, Faller RV. Erosion protection comparison of stabilised SnF2, mixed fluoride active and SMFP/arginine-containing dentifrices. Int Dent J 2014;64 Suppl 1:22-8.
- Faller RV, Eversole SL, Saunders-Burkhardt K. Protective benefits of a stabilised stannous-containing fluoride dentifrice against erosive acid damage. Int Dent J 2014;64 Suppl 1:29-34.
- Faller RV, Eversole SL. Enamel protection from acid challenge--benefits of marketed fluoride dentifrices. J Clin Dent 2013;24(1):25-30.
- O'Toole S, Bartlett D, Moazzez R. Efficacy of sodium and stannous fluoride mouthrinses when used before single and multiple erosive challenges. Australian dental journal 2016;61(4):497-501.
- Amaechi BT, Higham SM. Dental erosion: possible approaches to prevention and control. J Dent 2005;33(3):243-52.
- Attin T, Knofel S, Buchalla W, Tutuncu R. In situ evaluation of different remineralization periods to decrease brushing abrasion of demineralized enamel. Caries Res 2001;35(3):216-22.
Topic last updated: June 14, 2017
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