Erosive Tooth Wear

Dental erosion has been defined as the irreversible loss of dental hard tissue from acids, without the involvement of bacteria.^1-4 Etiology is multifactorial and can be from intrinsic (often due to acid reflux) or extrinsic sources (diet, particularly soft drinks; and industrial or environmental chemicals).^{2, 3, 5} 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.^6-8

Prevalence is understudied but rates in various countries have been reported from 5% to 97%.⁹ A 2012 study of Greek adults found a prevalence rate of 28.6% among 840 individuals aged 18 to 30 years,9 and a more recent meta-analysis (2015)¹⁰ showed 34.1% of 16,661 children and adolescents worldwide exhibited dental erosion. In the U.S., the National Health and Nutrition Examination Survey (NHANES, 2003-2004) reported an estimated prevalence of 45.9% among children¹¹ and up to 80% among adults.¹²

Intrinsic Causes

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.^{5, 10} 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, 5, 13}

• Gastroesophageal reflux. The regurgitation of stomach acids following meals, especially after overeating, is considered normal^{5, 10} for up to about 1 hour a day.³ However, in people with GERD, the introduction 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,⁵ and GERD has been noted as a common comorbidity of several chronic respiratory conditions.^14-16

Figures, below. Moderate to severe erosion from GERD in the primary dentition.

• Bulimia. Bulimia nervosa is an eating disorder that is characterized by intentional vomiting as a means to maintain a desired weight.^{3, 5, 17} It is a relatively common disorder among women in Western industrialized nations, with a prevalence of approximately 5% in 18-35 year old females.⁵ Among individuals with bulimia, the prevalence of erosion has been reported to be over 90%.⁵ 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, 5} 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,¹⁸ and non-purging bulimia which is characterized by periods of fasting and excessive exercise.

Figures, below. Characteristic erosion pattern from bulimia.

• Chronic Alcoholism. Alcoholism, with a prevalence of around 10% in Western countries,⁵ can result in erosion due to frequent vomiting and/or increased regurgitation.^{5, 19} Erosion in individuals with alcoholism can also be exacerbated by the consumption of acidic drinks.^{7, 13} In one study, erosion was found in 92% of 37 patients with alcoholism,⁵ and in a more recent study,¹⁹ 49.4% of the teeth of 50 individuals with alcoholism were found to show signs of erosion.¹⁹ 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 teeth.^{5, 19}


• 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.⁵

Extrinsic Causes

Unlike intrinsic factors for dental erosion, erosion due to extrinsic factors may be a combination of dietary, lifestyle, environmental or occupational factors that expose teeth to acids in beverages^{2, 3, 5} or inorganic acid vapors released into the environment.^{2, 5}

• Beverages. Arguably the most significant cause of extrinsic dental erosion^{1, 3, 10} are soft drinks, sports 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, 13, 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 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 studies^{10, 13, 23, 24} support the hypothesis that dietary acids are a major contributing factor in dental erosion.^{5, 25} A 2012 meta-analysis found more than double the risk of erosion from soft drinks as well as an increase in risk from chewable vitamin C tablets.²⁴ Many studies, including a 2015 meta-analysis, find that natural fruit juices as well as carbonated soft drinks and acidic, sweet snacks and sweet-sour candies to be significant erosion risk factors.^{10, 26}


• 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 and excessive use of vinegar-based dressings can lead to increased erosion.^{27, 28}


• 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, attributed to lowering of the water’s pH balance.^{1, 2, 7}

Since dental erosion is irreversible, the focus of erosion intervention is prevention and reduction, followed by management.¹³ Management includes lifestyle and diet changes, and, if necessary, restorative treatment to halt progression of erosive lesions.¹³

Some studies have found that milk and yogurt products (presumably unsweetened) may have a protective effect against erosion^{10, 13, 24} because of their calcium and phosphate content.²⁴ Calcium supplemented to acidic beverages, and other calcium-enriched products, have been suggested as protective alternatives to soft and sports drinks,^{13, 24} but not well studied as to their efficacy. Fluoride may contribute to remineralization of enamel,^{6, 29} but others have warned that fluoride’s “ability to prevent erosion cannot be presumed.”²

More recently, however, several in situ studies^30-36 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 straining the liquid between the teeth, or holding the liquid in the mouth.^{2, 13} Use of a straw positioned behind the front teeth is recommended to avoid bathing the teeth.¹³
• Drink water while eating, or rinse the mouth with water after consuming acidic drinks, candies, or foods.^{3, 24}
• After vomiting, rinse the mouth with water, a sodium bicarbonate rinse, or milk.^{3, 24, 37, 38}
• 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, 10, 39} Some researchers suggest waiting a half hour to one hour after eating, drinking, or vomiting.^{3, 40}
• Brush teeth using a soft bristle brush and fluoride toothpaste.³⁹ Look for products that carry the 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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2. Zero DT. Etiology of dental erosion--extrinsic factors. Eur J Oral Sci 1996;104(2 ( Pt 2)):162-77.
3. 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.
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10. 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.
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14. 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.
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19. 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.
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22. 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.
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24. Li H, Zou Y, Ding G. Dietary Factors Associated with Dental Erosion: A Meta-Analysis. PLOS ONE 2012;7(8):e42626.
25. 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.
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30. 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.
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33. 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.
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36. 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.
37. Alves Mdo S, Mantilla TF, Bridi EC, et al. Rinsing with antacid suspension reduces hydrochloric acid-induced erosion. Arch Oral Biol 2016;61:66-70.
38. Zero DT. Evidence for biofilm acid neutralization by baking soda. J Am Dent Assoc 2017;148(11S):S10-S14.
39. Amaechi BT, Higham SM. Dental erosion: possible approaches to prevention and control. J Dent 2005;33(3):243-52.
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Professional Resources

ADA Oral Health Topics: Chewing Gum

Search JADA for articles related to erosion

ADA Library Services

Information Sheet on pH of Home Oral Care Products

Patient Resources

MouthHealthy.org:

• Erosion: What You Eat and Drink Can Impact Teeth
• Erosion: Stomach Upset and Your Teeth
• Eating Disorders
• Top 9 Foods that Damage Your Teeth
• 4 Reasons Why Water is Good for Your Teeth