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JÚNIO S. ALMEIDA E SILVA, DDS, MSC*†, LUIZ NARCISO BARATIERI, DDS, MSC, PhD‡,

EDSON ARAUJO, DDS, MSC, PhD§, NICOLAS WIDMER, DDS, PhD¶

ABSTRACT

Dental erosion is a contemporary disease, mostly because of the change of the eating patterns that currently exist insociety. It is a “silent” and multifactorial disease, and is highly influenced by habits and lifestyles.The prevalence of dentalerosion has considerably increased, with this condition currently standing as a great challenge for the clinician, regardingthe diagnosis, identification of the etiological factors, prevention, and execution of an adequate treatment.This articlepresents a dental erosion review and a case report of a restorative treatment of dental erosion lesions using acombination of bonded ceramic overlays to reestablish vertical dimension and composite resin to restore the wornpalatal and incisal surfaces of the anterior upper teeth. Adequate function and esthetics can be achieved with thisapproach.

CLINICAL SIGNIFICANCE

It is essential for the practitioner to establish a correct and early diagnosis of dental erosion, as this condition is ofgrowing concern and is becoming more prevalent in current society.

(J Esthet Restor Dent 23:205–218, 2011)

INTRODUCTION

Tooth wear seems to be one of the most concerningproblems of the current dental practice. The etiology ofthis wear comes from well-known mechanicalprocesses, such as attrition, abrasion, and abfraction,and also from a chemical process, which is dentalerosion.

Currently, dental erosion is a great challenge for thepractitioner as far as diagnosing the condition,identifying the etiological factors, executing an adequatetreatment, and instituting preventive measures.

Tooth wear, when noticed, is frequently diagnosed asabrasion and attrition. Usually, when lesions caused byerosive challenges are identified, the lesions are alreadyin advanced stages. There are occasions when patientsnotice that their teeth are shortened or thinner beforetheir dentists.

As a matter of fact, most practitioners do not seem tobe sufficiently informed and are unable to fully establisha correct diagnosis regarding the etiology of tooth wear.Although there is usually not only one etiological factorcontributing to the loss of hard dental tissue, it isimportant that dental practitioners be aware that

*PhD student, Operative Dentistry Division, Federal University of Santa Catarina, Florianópolis, Brazil†Visiting Researcher, Department of Prosthetic Dentistry, Ludwig-Maximilians University, Munich, Germany‡PhD Professor and Chair, Operative Dentistry Division, Federal University of Santa Catarina, Florianópolis, Brazil§PhD Assistant Professor, Integrated Clinic, Operative Dentistry Division, Federal University of Santa, Catarina, Florianópolis, Brazil¶DDS, PhD, Federal University of Bern, Switzerland

ORIGINAL ARTICLE

© 2011 Wiley Periodicals, Inc. DOI 10.1111/j.1708-8240.2011.00451.x Journal of Esthetic and Restorative Dentistry Vol 23 • No 4 • 205–216 • 2011 205

erosion lesions are sequela from intrinsic or extrinsicacid attacks and may possibly be identified years afterthe beginning of the erosion activity.

This article reviews the literature with regards to themain aspects of dental erosion while also presenting acase report of a restorative treatment of dental erosionlesions using a combination of bonded ceramic overlaysto reestablish vertical dimension and composite resin torestore the worn palatal and incisal surfaces of theanterior upper teeth.

DENTAL EROSION

Dental erosion is a progressive loss of dental tissuecaused by chemical processes without bacterialinvolvement.1 It is a “silent,” multifactorial disease, andis highly influenced by personal habits and lifestyles.Erosion can be attributed to numerous factors,including the ingestion of organic and inorganic acidicsubstances. Acids responsible for dental erosion comefrom intrinsic and extrinsic sources.1–3

Extrinsic erosion is caused by exogenous acids that maycome from an individual’s diet, work environment,swimming pool water, medicine, and from some drugs.2

Intrinsic erosion is the result of endogenous acids thatcontact teeth during vomiting and regurgitation events,especially in patients who suffer from gastroesophagealreflux disease (GERD) and bulimia nervosa.1,2

Dental erosion occurs either by hydrogen ion attack orby the action of chelating anions.4 The process of dentalerosion is modulated by various determinants andmodifying factors, which will be discussed further.

BIOLOGICAL CONSEQUENCES

The result of constant exposure to erosive agentspromotes changes in the physical properties of dentalstructures. The result of episodic exposure to acidicchallenges decreases enamel microhardness,5 whichupon exposure to mechanical forces, makes the dentalsurface more susceptible to disruption. When the

erosive process occurs in dentin, the dentin-pulpcomplex responds to the attacks by producingreactionary dentin and occluding the dentinal tubules inorder to compensate for the tissue loss. If theprogression of dental erosion surpasses the dentin-pulpcomplex reparative capacity, there might be somecomplications, such as toothache, dental sensitivity,pulpal inflammation, pulp necrosis, and periapicallesions.3

CLINICAL CONSEQUENCES

The primary signs of dental erosion are: diminishingenamel luster; absence of macroscopic plaque; anddental surfaces that have become rounded and polishedbecause of the loss of microanatomy. After the initialdental erosion, some features can be observed, such assmoothing out of developmental pits and grooves,dentin exposure, prominent restorations that areelevated above the surrounding tooth structure, andwell-defined concavities of dentin on the occlusal andincisal surfaces, especially on the cusp tips of theposterior teeth.6 In more advanced cases, extensivemineral loss can lead to tooth shortening, which canpromote functional and esthetic problems.

Convex teeth areas, such as proximal ridges, graduallybecome flat and even concave. In severe cases, dentalmorphology can be totally lost (Figures 1 and 2). Dentalerosion in patients who have exposed root dentin may

FIGURE 1. Dental erosion by abusive intake of citric fruitjuices. Maxillary teeth display loss of microanatomy andpolished and rounded surfaces. Observe the dentin exposureon the labial surface of the maxillary right incisor.Theproximal ridges of the maxillary left and right incisors presenta diminishing of the natural convexity.

DENTAL EROSION Almeida e Silva et al

Vol 23 • No 4 • 205–216 • 2011 Journal of Esthetic and Restorative Dentistry DOI 10.1111/j.1708-8240.2011.00451.x © 2011 Wiley Periodicals, Inc.206

develop more rapidly because of the lower dissolutionresistance that dentin presents.3–6 If there is noprofessional intervention and elimination of theetiological factors, the outcome of this disease may bethe total loss of the teeth.

PREVALENCE AND INCIDENCE OFDENTAL EROSION

Both the prevalence and incidence of dental erosionhave considerably increased, mainly among youngadults and children.1–10 Lifestyles have changed throughthe decades, with the consumption of acidic food andcarbonated beverages increasing.7 Currently, fast foodconsumption is a common factor in society. Thepopularity of this kind of food item, along with theappealing publicity that seduces children and teenagers,may bring some harmful consequences, such as dentalerosion.

Soft drink consumption in the United States increasedby 300% over the last 20 years, with serving sizesincreasing from 185 g in the 1950s to 340 g in the 1960sand to 570 g in the late 1990s.11 It seems unavoidablethat the increase of soft drink intake may lead topathological tooth wear. Around 1995, between 56 and85% of school-aged children in the United Statesconsumed at least one soft drink daily.12

Generally, specific epidemiological surveys of toothwear are not routinely undertaken. There are, however,some isolated surveys that evaluate the prevalence ofdental erosion in different populations with differentages.9–13 It is difficult to establish comparisons betweensurveys because of the different samples and evaluationmethods applied on each one. However, there is aconsensus that tooth wear is a common condition andcan be started as soon as the first tooth surface reachesthe oral cavity and is exposed to erosive agents.Deciduous and permanent teeth are equally involved.Additionally, if occlusal stress is present, theprogression of erosion increases considerably.9 Erosivetooth wear can be found on every surface of all teeth.9

Taking into consideration the social and culturaldifferences of each population, a common factor isevident: there is a greater prevalence of dental erosionamong young adults and children, which is associatedwith the consumption of acidic food and beverages,psychosomatic eating disorders, and current lifestyles.

RISK GROUPS

Risk groups are comprised of those individuals thatpresent one or more dental erosion etiological factor(s).In order to didactically organize them, they have beendivided into extrinsic and intrinsic erosion groups. It isimportant though to emphasize that there are patientswho present both types of dental erosion (extrinsic andintrinsic) simultaneously.

Extrinsic Erosion

This group is constituted by those whose teeth arefrequently attacked by exogenous acids, such as softdrinks, fruit juices, pickles, fresh fruits, and yogurt;essentially, the majority of food that presents a pHlower than the critical value for enameldemineralization.14 Also included in this group areindividuals that: abusively use vinegar on salads or lowpH mouth rinses15; are daily exposed to acidic workingenvironment16; frequently ingest electrolyticreplenishers2; and take illicit drugs, such asmethamphetamine, cocaine, and ecstasy1,17,18 (Figure 1).

FIGURE 2. Dental erosion by bulimia nervosa. Observe theloss of occlusal enamel, dentin exposure and prominentamalgam restorations on the molars. Dentin concavities, whichare present on the occlusal surfaces of the molars, are formeddue to the difference of the acid dissolution progressionbetween dentin and the surrounding enamel.The premolarocclusal surface displays a loss of microanatomy, diminishingenamel luster, and a smoothing out of the developmental pitsand grooves.



Intrinsic Erosion

This group is composed of patients whose teeth areattacked by endogenous acids during recurrentvomiting, regurgitation, or reflux. Gastroesophagealreflux, which is the major cause of intrinsic erosion, is acondition where acids from the stomach areregurgitated back to the oral cavity,9 thus resulting inconstant oral exposure to an acidic environment.1

Psychosomatic eating disorders, such as bulimianervosa and anorexia nervosa, are usually the maincause of vomiting and regurgitation. Also included inthis group are alcoholics and patients that presentgastrointestinal disorders, hiatal hernia, peptic, andduodenal ulcers.2–6 (Figures 2–4).

PATHOPHYSIOLOGY OF DENTAL EROSION

The direct effect of the attack of hydrogen ions on thetooth surface is to combine with carbonate, phosphate,or both, and detach the mineral ions from the surface.Some acids, such as citric acid, have a more complexinteraction. In water, these acids are dissociated intohydrogen ions and acidic anions. The hydrogen ions actexactly as aforementioned and directly attack the crystalsurface whereas the acidic anions act by chelatingcalcium from the crystal surface. These acids have adouble action and are very damaging to the toothsurface.4

How Enamel and Dentin React to Attacksby Erosive Agents

In order to contact enamel, a solution has to diffusethrough the acquired pellicle, only then can it interactwith enamel.7 On the enamel surface, the hydrogen ionsor chelating agents start to dissolve the enamel crystal.First, the prism sheath area and then the prism core aredissolved, leaving a honeycomb appearance. Then, freshand unionized acids will diffuse into the interprismaticareas of enamel and further dissolve the mineralcontent underneath the surface. This further acid attackwill lead to an outflow of ions and a rise in the pH inthe surrounding environment.3,4,7 When there is anelevation of the surrounding pH because of saturationof mineral ions, remineralization of the softened tissuesthat have not been directly etched away may occur,from the released ions and from other sources. If

FIGURE 3. Dental erosion by gastroesophageal reflux disease. Observe the loss of palatal enamel of the maxillary teeth. Noticethat, when occluding (right), the mandibular right incisor exclusively contacts the amalgam restoration of the maxillary right incisor.

FIGURE 4. Young patient with gastroesophageal refluxdisease. Notice that, due to the intrinsic source of acids, thepalatal surfaces are worn more rapidly than the labial surfaces,thus leaving the incisal third with a sharpened bladeappearance.



fluoride is present in the oral environment, fluorapatitecan be formed, which is less soluble than the originalenamel.4

The effects of acids on dentin have been largelyinvestigated, as the length of time that teeth remain inthe mouth is increasing, with dentinal coronal and rootexposures that are gradually becoming commonbecause of tooth wear and gingival recession,respectively.19 The initial events in dentindemineralization are similar to those that occur in theenamel. However, because of the high organic contentof dentin, diffusion of the demineralizing agents andmineral ions are partially stopped by the organic matrix,which acts as a barrier to acid diffusion and mineralrelease, thereby reducing the progression of the erosiveprocess.12–24 This difference in erosive processesbetween enamel and dentin does not mean that theerosive process in dentin is slower, on the contrary, thedentin substrate is more susceptible to acid dissolutionbecause its hydroxyapatite crystals are smaller than thatof enamel. Thus, there is a larger susceptible area foracid attack,4 as found in dentinal concavities, or dentalerosion clinical signs that are formed because of thedifferent rates of acid dissolution between dentin andthe surrounding enamel.

DETERMINANT FACTORS ON THEMODULATION OF DENTAL EROSION

The development of dental erosion is stronglyinfluenced by determinant factors (biological, chemical,and behavioral) and by modifying factors (knowledge,systemic health, and socioeconomic status).

Biological Factors

SalivaSaliva is the most important biological factor for themodulation of dental erosion. Saliva protects teeth bydiluting and eliminating erosive agents from the oralenvironment and through its acid neutralization andbuffering capacity. Saliva plays a role in reducingdemineralization by forming acquired pellicle andaiding the adsorption of proteins and glycoproteins,

while enhancing remineralization by providing calcium,phosphate, and fluoride to eroded enamel and dentin.25

The relevance of saliva on the erosion process may bedemonstrated by in vitro—no salivary protection and insitu—with salivary protection comparisons. In a studyby West and colleagues26 enamel erosion was drasticallyreduced, by the order of 10 times, in the in situ model.

The quantity and quality of saliva are equally importanton the modulation of erosive agent attacks on the toothsurface. The bicarbonate level of saliva is directlyrelated with salivary flow; therefore, saliva produced atlow flow rates presents low pH and a reduced bufferingcapacity.2 The impact of dental erosion in patients withsalivary flow deficiencies clearly demonstrates theimportance of saliva on the erosive process, which isdemonstrated in studies that have linked low bufferingcapacity and salivary flow to dental erosion.27–30

Acquired PellicleAcquired pellicle is a protein-based layer that is rapidlyformed on the tooth surface, shortly after its removal bytooth brushing, prophylaxis, or chemical dissolution.19

This pellicle protects teeth because it acts as a barrier,or a semipermeable membrane, which prevents thedirect contact of erosive agents on the tooth surfaceand serves as reservoir of remineralizing electrolytes,31

which may influence the development of erosion.19

With this in mind, it is important to instruct patients tonot brush their teeth immediately before consumingacidic food or drink because it removes the acquiredpellicle, thus leaving teeth less protected.

Tooth StructureSusceptibility to dental erosion may vary according toeach patient, as the developmental pattern of thisdisease may be influenced by the clinical history of eachpatient. This different developmental pattern is causedby different situations that can impair or modify thetooth, such as mechanical or chemical processes thatinclude caries, erosion, abrasion, attrition, andabfraction.19 With regards to tooth composition,exposure to saliva and fluorides have demonstratedeffectiveness on the remineralization of eroded enamel.Therefore, a structural difference, such as the formation



of fluorapatite, may influence and modulate thedevelopment of dental erosion.32,33

There is some controversy regarding the susceptibilityof deciduous teeth to dental erosion compared to thepermanent dentition. Because of differences inmineralization, permanent teeth are less prone to aciddissolution than deciduous teeth.19 However, it has alsobeen reported that there are no differences in aciddissolution susceptibility between these two substrateswhen exposed to acidic beverages in an in vitrocomparison.34 Although there is a higher prevalence ofdental erosion among children when compared withadults, this difference might be caused by a greaterconsumption of acidic food and beverages and to theoverlap of the erosive challenge with abrasiveprocedures, as the primary enamel is supposed to beless resistant to abrasion.19,34–36

Soft TissuesSoft tissues play a role in tooth wear. One of the mostsevere manifestations of dental erosion is found onpalatal surfaces of the upper teeth due to mechanicalabrasion from the tongue on the dental tissue just afterthe consumption of an erosive agent.2

BEHAVIORAL FACTORS

Although biological factors influence the response ofeach person to dental erosion, behavioral patternsinfluence the biological response to erosive challengesbecause they are capable of modifying the oralenvironment by turning it more or less susceptible tothe development of dental erosion. Behavioral aspectsinfluence the intensity, localization, and type of erosionlesions.

Unhealthy Lifestyles

Alcoholic individuals may be at risk of developingdental erosion due to the symptoms of alcoholism, suchas recurrent vomiting and gastrointestinal reflux.37

The usage of drugs such as “ecstasy”(3,4-methylenedioxy-methamphetamine) is known for

causing tooth wear. Ecstasy users report symptomssuch as dry mouth, hyperthermia, clenching, andgrinding during dances or “raves” even hours after themental effects of the drugs, indicating that the physicalwear may continue for some time after the drugconsumption. The dry mouth and general hyperthermiaare usually relieved by drinking soft drinks, many ofwhich are acidic and thus, potentially erosive to theteeth. The influence of grinding or clenching frombruxist activity is heightened in a mouth with poorsalivary lubrication.17 As indicated previously, a lowsalivary flow theoretically means the presence of a lowbuffering capacity; thus, acid erosion is increased underthis condition. This combination of habits andsymptoms may manifest as greater levels of toothwear.38 The common reluctance of the patient toadmit to the use of such drugs impairs theestablishment of an accurate diagnosis and appropriatetreatment plan.

Healthy Lifestyles

Although it seems to be contradictory that a healthylifestyle may be linked to a disease, it is important toemphasize that people involved in sports and exercisemay be at risk of developing dental erosion due to theconsumption of sport drinks, replenishers, fruit juices,and other acidic beverages. The benefits of exerciseare well proven; however, exercise increases the loss ofbody fluids and may lead to dehydration and a reduc-tion of salivary flow. The need for fluid intake, tosatisfy an energy requirement, during a time ofdecreased salivary flow can create a proper conditionfor the development of dental erosion. Theconsumption of fruits and juices is part of several dietplans, which also may put those on such plans atgreater risk of developing dental erosion.2

Nutritional Habits

Nutrition plays a key hole in dental erosion. Theingestion of low pH products may causedemineralization of dental hard tissues. Dental erosioncan occur due to the frequent intake of soft drinks, fruitjuices, pickles, fresh fruits, yogurt, and other food items.



Habits such as lemon sucking and soft drink swishingexpose enamel and dentin to an acidic environment fora longer period of time, which may cause greaterdemineralization. The consumption of acidic foods andbeverages among patients with dental erosion is higherthan among regular patients.39

Phosphoric acid, usually found in soft drinks, isthree times more erosive than organic acids. Theincidence of dental erosion in a population grows withan increase in consumption of soft drinks. Citric,tartaric, maleic, and lactic acids are examples oforganic acids. Citric and maleic acids are predominantlyfound in fruits and in their derivate products. Tartaricacid is present in grapes and wines. Dental erosion mayoccur when any of these beverages or foods isabused.40,41

Vegetarian diets, in which fruit consumption may bemore than 66% of the overall food intake, may leadtheir followers to develop dental erosion.40

CHEMICAL FACTORS

The term “chemical factors” is used to describeparameters inherent to erosive beverages, food, andother products.42 The chemical properties of the foodplay an important role in dental erosion. The erosivepotential of foods and beverages does not dependexclusively on the pH value, but also upon their mineralcontent, buffering capacity, and calcium-chelationproperties. The pH value and calcium and fluoridecontent of a drink or foodstuff determines the degree ofmineral saturation with respect to the teeth, which isthe driving force for erosion,42 as supersaturatedsolutions are not capable of dissolving tooth structure.There is no clear-cut critical pH for erosion as there isfor caries, for even at a low pH, it is possible that otherfactors are strong enough to prevent erosion.42

Therefore, components such as calcium, phosphate, andfluoride may lessen the erosive capacity of some drinksand foods.9 For instance, some orange juices areenriched with calcium in order to reduce their erosivepotential.43

MODIFYING FACTORSOF DENTAL EROSION

Systemic Health

Some systemic diseases, such as Sjögren’s syndrome;medicines, such as acetylsalicylic acid when taken daily;hydrochloric acid for treatment of stomach disorders,diuretics and antidepressive medicines and therapiesthat involve irradiation of salivary glands all adverselyaffect salivary production, thus interfering with thebiological protection provided by saliva. Even withoutexcessive exposure to erosive agents, hyposalivationmay induce dental erosion, as low salivary flow leads tolow buffering capacity; therefore, acid elimination in theoral cavity is decreased as well as the salivaremineralization capacity.44

Knowledge

An awareness of the risks and activity of dental erosion,as well as an understanding of the erosive potential ofdrinks and foodstuff, is an important aspect in changingthe initiation and progression of this disease. Patientswho show signs and symptoms of dental erosion areoften not aware of, and might be confused about, theerosive characteristics of items of their diet7 or aboutany modifying factors their dietary intake might have. Athorough knowledge of all the dental erosion features isalso needed by the dentist in order to determine thepatient’s risk of dental erosion and to institutepreventive and curative measures.

Socioeconomic Status

Socioeconomic status might be linked to many of thepreviously mentioned factors, such as systemic healthand knowledge, and thus indirectly influence thedevelopment of dental erosion. They can determine thequality of the dental evaluation, which might lead to anincorrect diagnosis and treatment. Nevertheless,whether dental erosion is a disorder of affluenceremains unclear. However, social deprivation might alsobe related to nonfluoridated districts. Children innonfluoridated districts are 1.5 times more likely to



have smooth surface wear compared with children influoridated districts.45 Although the literatureconcerning the influence of socioeconomic status ondental erosion is still conflicting, the trend is for moretooth wear among the children not exposed tofluoridation of their residential water supply, furthersupporting a protective role.45

INTERACTION OF DENTAL EROSION ANDMODIFYING FACTORS

Many people, with different modifying factors,frequently ingest fruit juices, carbonated beverages, andacidic foods that have an erosive potential. Therefore,the question is: Why do many people maintain theirteeth for a lifetime, considering that they are constantlyexposed to erosive challenges every day? On the otherhand, why do some people suffer rapid and irreversibledestruction of their teeth by erosion?2

The development and intensity of dental erosiondepends on the interplay of the previous factors.7

Determinant factors play a direct role in thedevelopment of dental erosion, whereas modifyingfactors synergistically act on this disease. Over time, thebiological, behavioral, and chemical factors, along withthe modifier factors and their possible combinations,might start or prevent dental erosion.7 Hydrogen ionconcentration alone does not explain the erosivepotential of food and drink. All factors must be takeninto consideration. The interplay of these factors iscrucial and helps explain why some individuals exhibitmore erosion than others, while also addressing thereason why, even when exposed to the same acidchallenge in their diets, some people present distinctpatterns of this disease, since each patient may showdifferent modifying factors that produce differentdevelopmental patterns of dental erosion.

CASE REPORT

The following case is a restorative treatment of intrinsicerosion lesions, involving ceramic restorations on themaxillary and mandibular posterior teeth and compositeresin restorations on the anterior maxillary teeth.

The etiology of this specific dental erosion wasgastroesophageal reflux, which was corrected using amultidisciplinary approach involving agastroenterological evaluation and treatment. Thepatient’s main complaint was wear of the posteriorteeth. Although the posterior teeth displayed noticeablewear, a clinical exam showed wear on the palatalsurfaces of the anterior maxillary teeth as well.

The treatment plan was divided into two steps: increaseof vertical dimension of occlusion (VDO) with indirectceramic restorations on the posterior segment anddirect composite resin restorations on the anteriorsegment.

After plaster models of both jaws were taken and waxbuild-up, a new VDO was created by the technician.The new VDO was tested on the patient withprovisional overlays placed on the maxillary andmandibular posterior teeth. Then, the posterior teethwere prepared and ceramic onlays and overlays wereplaced on the posterior maxillary and mandibular teeth,with the exception of the maxillary left and rightsecond molars, which did not display wear. Once thenew VDO was reestablished with the posterior ceramicrestorations, space was made to restore the worn palataland incisal surfaces of the anterior maxillary teeth withcomposite resin.

Ceramics IPS Empress e.max (Ivoclar Vivadent, Schaan,Liechtenstein) was the material of choice for posteriorsegment due to its high longevity, maintenance ofesthetic features such as anatomical form, color,adhesive bonding to dental hard tissues,46,47 and alsobecause one of the patient’s demands was along-lasting, esthetic and not time-consumingrehabilitation. Since no severe wear was present on thelabial surfaces of the maxillary anterior teeth only theworn palatal and incisal surfaces were restored withcomposite resin because it is a reversible non-invasivetechnique that allowed us to preserve the labial surfacesof the maxillary anterior teeth. It is an esthetic solutionand not time-consuming compared with indirectrestorations. Function and esthetics were achieved withthis approach (Figures 5–17).



FIGURE 5. Observe the erosive tooth wear at the labialsurface as well as at the incisal third of the maxillary incisors.

FIGURE 6. Observe the palatal erosive tooth wear.

FIGURE 7. Right hemi-arches.

FIGURE 8. Left hemi-arches.

FIGURE 9. Observe the erosive tooth wear severity.Almostthe entire occlusal enamel has been worn away.

FIGURE 10. Occlusal view of the mandibular posterior teethpreparations.



FIGURE 13. Right hemi-arches. Occlusal views after placement of the ceramic restorations.

FIGURE 14. Left hemi-arches. Occlusal views after placement of the ceramic restorations.

FIGURE 15. Lateral views after restorative treatment. FIGURE 16. Frontal view after composite resin restorations,note the increase of vertical dimension.

FIGURE 11. Occlusal view of the maxillary posterior teethpreparations before the luting procedures.

FIGURE 12. View after placement of the ceramicrestorations on the maxillary posterior teeth.



CONCLUSION

Regardless of the etiology of dental erosion, it is rarelydiagnosed at its early stages. Often, a multidisciplinaryapproach, potentially involving gastroenterological andpsychological evaluations, is necessary. Awareness andunderstanding of this disease and the factors thatmodify it is crucial for establishing an early diagnosisand preventive and/or restorative treatment.

DISCLOSURE AND ACKNOWLEDGEMENTS

The authors thank Sylvio Monteiro Jr., DDS, MSc, andPhD, for his assistance. The authors do not have anyfinancial interest in the companies whose materials areincluded in this article.

REFERENCES

1. Lussi A. Erosive tooth wear—a multifactorial condition ofgrowing concern and increasing knowledge. In: Lussi A,editor. Dental erosion—from diagnosis to therapy. Bern:Karger; 2006, pp. 1–8.

2. Nunn JH, Gordon PH, Morris AJ, et al. Dentalerosion—changing prevalence? A review of Britishnational childrens’ surveys. Int J Pae Diatr Dent2003;13(2):98–105.

3. Jaeggi T, Lussi A. Prevalence, incidence anddistribution of erosion. In: Lussi A, editor. Dentalerosion—from diagnosis to therapy. Bern: Karger; 2006,pp. 44–65.

4. Shipley S, Taylor K, Mitchell W. Identifying causes ofdental erosion. Gen Dent 2005;53(1):73–6.

5. Moss SJ. Dental erosion. Int Dent J 1998;48(6):529–39.6. Ganss C. Definition of erosion and links to tooth wear.

In: Lussi A, editor. Dental erosion—from diagnosis totherapy. Bern: Karger; 2006, pp. 9–16.

7. Featherstone JDB, Lussi A. Understanding the chemistryof dental erosion. In: Lussi A, editor. Dentalerosion—from diagnosis to therapy. Bern: Karger; 2006,pp. 66–76.

8. Attin T, Koidl U, Buchalla W, et al. Correlation ofmicrohardness and wear in differently eroded bovinedental enamel. Arch Oral Biol 1997;42(3):243–50.

9. Cardoso AC, Canabarro S, Myers SL. Dental erosion:diagnostic-based noninvasive treatment. PractPeriodontics Aesthet Dent 2000;12(2):223–8.

10. Luo Y, Zeng XJ, Du MQ, Bedi R. The prevalence ofdental erosion in preschool children in China. J Dent2005;33(2):115–21.

11. Calvadini C, Siega-Riz AM, Popkin BM. US adolescentfood intake trends from 1965 to 1996. Arch Dis Child2000;83(1):18–24.

12. Gleason P, Suitor C. Children’s diet in the mid 1990s:dietary intake and its relationship with school mealparticipation. US Department of Agriculture, Food andNutrition Service, Office of Analysis, Nutrition andEvaluation 2001.

13. Lussi A, Shaffner M, Hotz P, et al. Dental erosion in apopulation of Swiss adults. Community Dent OralEpidemiol 1991;19(5):286–90.

14. Al-Malik MI, Holt RD, Bedi R. The relationship betweenerosion, caries, rampant caries and dietary habits inpreschool children in Saudi Arabia. Int J Pediatr Dent2001;11(6):430–9.

15. Pontefract H, Hughes J, Kemp K, et al. The erosive effectsof some mouthrinses on enamel. A study in situ. J ClinPeriodontol 2001;28(4):319–24.

16. Amin WM, Al-Omoush SA, Hattab FN. Oral healthstatus of workers exposed to acid fumes in phosphateand battery industries in Jordan. Int Dent J2001;51(3):169–74.

17. Richards JR, Brofeldt BT. Patterns of tooth wearassociated with methamphetamine use. J Periodontol2000;7(8):1371–4.

18. Milosevic A, Agrawal N, Redfearn P, et al. Theoccurrence of toothwear in users of ecstasy(3,4-methylenedioxymethamphetamine). CommunityDent Oral Epidemiol 1999;27(4):283–7.

19. Hara AT, Lussi A, Zero DT. Biological factors. In:Lussi A, editor. Dental erosion—from diagnosis totherapy. Bern: Karger; 2006, pp. 88–99.

20. Vanuspong W, Eisenburger M, Addy M. Cervical toothwear and sensitivity: erosion, softening and hardening of

FIGURE 17. Composite resin restorations of the palatalsurfaces of the maxillary anterior teeth.



dentine: effects of pH, time and ultrasonication. J ClinPeriodontol 2002;29(4):351–7.

21. Hara AT, Ando M, Cury JA, et al. Influence of the organicmatrix on root dentin erosion by citric acid. Caries Res2005;39(2):134–8.

22. Meurman JH, Frank RM. Scanning electron microscopicstudy of the effect of salivary pellicle on enamel erosion.Caries Res 1991;25(1):1–6.

23. Featherstone JDB, Rodgers BE. Effects of acetic, lactic andother organic acids on the formation of artificial cariouslesions. Caries Res 1981;15(3):377–85.

24. Lussi A, Hellwig E. Erosive potential of oral careproducts. Caries Res 2001;35(Suppl 1):52–6.

25. Mandel ID. The functions of saliva. J Dent Res1987;66:623–7.

26. West NX, Maxwell A, Hughes JA, et al. A method tomeasure clinical erosion: the effect of orange juiceconsumption on erosion of enamel. J Dent1998;26(4):329–35.

27. Jarvinen VK, Rytomaa II, Heinonen OP. Risk factors indental erosion. J Dent Res 1991;70(6):942–7.

28. Meurman JH, Toskala J, Nuutinen P, et al. Oral anddental manifestations in gastroesophageal reflux disease.Oral Surg Oral Med Oral Pathol 1994;78(5):583–9.

29. Bartlett DW, Coward PY, Nikkah C, et al. The prevalenceof tooth wear in a cluster sample of adolescentschoolchildren and its relationship with potentialexplanatory factors. Br Dent J 1998;184(3):125–9.

30. Rytomaa I, Jarvinen V, Kanerva R, et al. Bulimia and tootherosion. Acta Odontol Scand 1998;56(1):36–40.

31. Hannig C, Hannig M, Attin T. Enzymes in the acquiredenamel pellicle. Eur J Oral Sci 2005;113(1):2–13.

32. Feagin F, Koulourides T, Pigman W. The characterizationof enamel surface demineralization, and associatedhardness changes in human and bovine material. ArchOral Biol 1969;14(12):1407–17.

33. Zero DT, Fu J, Scott-Anne K, et al. Evaluation of fluoridedentifrices using a short-term intraoral remineralizationmodel [abstract 1363]. J Dent Res 1994;73:272.

34. Lussi A, Kohler N, Zero D, et al. A comparison of theerosive potential of different beverages in primary andpermanent teeth using an in vitro model. Eur J Oral Sci2000;108(2):110–4.

35. Jones SG, Nunn JH. The dental health of 3-year-oldchildren in east Cumbria. Community Dent Health1995;12(3):161–6.

36. Millward A, Shaw L, Smith AJ, et al. The distribution andseverity of tooth wear and the relationship betweenerosion and dietary constituents in a group of children.Int J Paediatr Dent 1994;4(3):151–7.

37. Hede B. Determinants of oral health in a group of Danishalcoholics. Eur J Oral Sci 1996;104(4 Pt 1):403–8.

38. Zero DT, Lussi A. Behavioral factors. In: Lussi A, editor.Dental erosion—from diagnosis to therapy. Bern: Karger;2006, pp. 100–5.

39. Gandara BK, Truelove EL. Diagnosis and management ofdental erosion. J Contemp Dent Pract 1999;1(1):16–23.

40. Ganss C, Klimec J, Borkowski N. Characteristics of toothwear in relation to different nutritional patterns includingcontemporary and medieval subjects. Eur J Oral Sci2002;110(1):54–60.

41. West NX, Hughes JA, Addy M. Erosion of dentin andenamel in vitro by dietary acids: the effect of temperature,acid character, concentration and exposure time. J OralRehabil 2000;27(10):875–80.

42. Lussi A, Jaeggi T. Chemical factors. In: Lussi A, editor.Dental erosion—from diagnosis to therapy. Bern: Karger;2006, pp. 77–87.

43. Grenby TH. Lessening dental erosive potential by productmodification. Eur J Oral Sci 1996;104(2 Pt 2):221–8.

44. Yip KHK, Smales RJ, Kaidonis JÁ. The diagnosis andcontrol of extrinsic acid erosion of tooth substance. GenDent 2003;51(4):350–3.

45. Bardsley PF, Taylor S, Milosevic A. Epidemiologicalstudies of tooth wear and dental erosion in 14-year-oldchildren in North West England. Part 1: the relationshipwith water fluoridation and social deprivation. Br Dent J2004;197(7):413–6.

46. Conrad HJ, Seong WJ, Pesun IJ. Current ceramicmaterials and systems with clinical recommendations: asystematic review. J Prosthet Dent 2007;98(5):389–404.

47. Della Bona A, Kelly JR. The clinical success of all-ceramicrestorations. J Am Dent Assoc 2008;139(Suppl):8S–13S.

Reprint requests: Júnio S. Almeida e Silva, DDS, MSC, Goethestrasse 70

Apt. 314, LMU Dental School, 80336 Munich, Germany;Tel.: 0049 89

51609439/15259723581; email: [email protected] or

[email protected]

This article is accompanied by commentary, Dental Erosion:

Understanding This Pervasive Condition,Terry Donovan, DDS

DOI 10.1111/j.1708-8240.2011.00452.x



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