Dental Erosions

8/4/2019 Dental Erosions

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DENTAL EROSION—TOOTH WEAR

Physiology, Etiology, Epidemiology, Diagnosis,

and Treatment

Reviewed by:



Dental Erosion: Tooth Wear After viewing this lecture, attendees should be able to:

• understand the oral anatomy and physiology as they relate to dental

erosion/tooth wear• identify the etiology of and risk factors associated with dental

erosion/tooth wear• describe the epidemiology and prevalence of dental erosion/tooth wear• make the correct differential diagnosis and understand the management of

dental erosion/tooth wear



Oral Anatomy and Physiology

•Primary (deciduous)

• Secondary (permanent)

Definition (teeth): There are two definitions



Primary (deciduous)

• Consist of 20 teeth

•Begin to form during the firsttrimester of pregnancy

• Typically begin erupting around 6months

• Most children have a completeprimary dentition by 3 yearsof age


Dentition (teeth): There are two dentitions

1. Oral Health for Children: Patient Education Insert. Compend Cont Educ Dent .




Secondary (permanent)

• Consist of 32 teeth in most cases

• Begin to erupt around 6 yearsof age

• Most permanent teeth haveerupted by age 12

• Third molars (wisdom teeth) arethe exception; often do not appearuntil late teens orearly 20s

Dentition (teeth): There are two dentitions

Mandible

Maxilla Incisors

Canine (Cuspid)

Premolars

Molars



Classification of Teeth:• Incisors (central and lateral)

• Canines (cuspids)

• Premolars (bicuspids)

• Molars


Identifying Teeth

Incisor Canine Premolar Molar



Oral Anatomy

and Physiology

•

Apical• Labial

• Lingual

• Distal

• Mesial

•

Incisal

Teeth: Identification

Tooth Surfaces

Labial

Apical

Lingual

Incisal Incisal

Distal

Apical

Mesial



• Anatomic Crown

• Anatomic Root

• Pulp Chamber

The 3 parts of a tooth:

Anatomic Crown

Anatomic Root

PulpChamber




•

Enamel• Dentin

• Cementum

• Dental Pulp

The 4 main dental tissues:


Enamel

Dentin

Cementum

Dental Pulp



• Structure – Highly calcified and hardest tissue in

the body

– Crystalline in nature – Enamel rods

• Insensitive — no nerves

• Acid-soluble — will demineralize at apH of 5.5 and lower

• Cannot be renewed

•

Darkens with age as enamel is lost• Fluoride and saliva can help with

remineralization

Dental Tissues—Enamel2




• Softer than enamel

• Susceptible to tooth wear

(physical or chemical)• Does not have a nerve supply but

can be sensitive

• Is produced throughout life

• Three classifications

– Primary

– Secondary

– Tertiary

• Will demineralize at a pH of 6.5and lower

Dental Tissues—Dentin2




Dentin

Pulp

Tubule

Fluid Nerve Fibers

OdontoblastCell

Oral Anatomy

and Physiology

•

Presence of tubules renders dentinpermeable to fluoride

• Number of tubules per unit area

varies depending on the location

because of the decreasing area of

the dentin surfaces in the pulpal

direction

Dental Tissues—Dentin (Tubules)2



Association between erosion anddentin hypersensitivity3

• Open/patent tubules

– Greater in number

– Larger in diameter

• Removal of smear layer

• Erosion/tooth wear

Enamel

ExposedDentin

RecedingGingiva

Tubules

Odontoblast

Oral Anatomy

and Physiology

Dental Tissues—Dentin (Tubules)2




• Thin layer of mineralized tissuecovering the dentin

• Softer than enamel and dentin

• Anchors the tooth to the alveolarbone along with the periodontalligament

• Not sensitive

Dental Tissue—Cementum2



• Innermost part of the tooth

• A soft tissue rich with blood vesselsand nerves

• Responsible for nourishing the tooth

• The pulp in the crown of the tooth isknown as the pulp chamber

• Pulp canals traverse the root of thetooth

• Typically sensitive to extremethermal stimulation (hot or cold)

Dental Tissue—Dental Pulp2




• Plaque

•

Saliva• pH Values

• Demineralization

• Remineralization

Oral Cavity/Environment4,5




Oral Anatomy

and Physiology

Plaque:4,5

• is a biofilm

• contains more than 600 differentidentified species of bacteria

• there is harmless and harmful plaque

• salivary pellicle allows the bacteriato adhere to the tooth surface, which

begins the formation of plaque

Oral Cavity



Oral Anatomy

and Physiology

Saliva:4,5

• complex mixture of fluids• performs protective functions:

– lubrication — aids swallowing

– mastication

– key role in remineralization

of enamel and dentin

– buffering

Oral Cavity



Oral Anatomy

and Physiology

pH values:4,5

• measure of acidity or alkalinity of asolution

• measured on a scale of 1-14

• pH of 7 indicated that the solution isneutral

• pH of the mouth is close to neutraluntil other factors are introduced

• pH is a factor in demineralization

and remineralization

Oral Cavity

3. Strassler HE, Drisko CL, Alexander DC.



Oral Anatomy

and Physiology

Demineralization:

4,5

• mineral salts dissolve into the

surrounding salivary fluid:

– enamel at approximate pH of

5.5 or lower

– dentin at approximate pH of 6.5

or lower• erosion or caries can occur

Oral Cavity



Oral Anatomy

and Physiology

Remineralization:4,5

• pH comes back to neutral (7)

• saliva-rich calcium and phosphates

• minerals penetrate the damagedenamel surface and repair it:

– enamel pH is above 5.5

–

dentin pH is above 6.5

Oral Cavity



Dental Erosion: Etiology

Destruction of the dental tissues (enamel, dentin, cementum) can

occur as a result of physical loss, chemical dissolution, and/ormultifactorial etiology.3,6

Tooth Wear



Destruction of the dental tissues (enamel, dentin, cementum) can occur as

a result of:3,6

• Physical Loss

– Abrasion — mechanical

– Attrition — tooth-to-tooth contact

– Abfraction — lesions

• Chemical dissolution

• Multifactorial etiology


Tooth Wear



Destruction of the dental tissues (enamel, dentin, cementum) can occur

as a result of:3,6

• Physical Loss


– Erosion

-- Extrinsic acids

-- Intrinsic acids



Tooth Wear



Destruction of the dental tissues (enamel, dentin, cementum) can occur as

a result of:3,6

• Physical Loss



– Erosion

– Abrasion

– Attrition

– Abfraction


Tooth Wear



The pathological wearing away of hard dental tissue through abnormal mechanical processes

involving foreign objects or substances repeatedly introduced in the mouth and contacting

the teeth.6

• Oral hygiene habits

– Excessive brushing/flossing

– Abrasives in dentifrices/toothpastes

• Personal habits

– Putting foreign objects in the mouth

•

Demastication – Wear from chewing food

Abrasion




The pathological wearing away of hard dental tissue as a result of tooth-to-tooth contact,

with no foreign substance intervening.6

• Enamel wearing enamel

– Occlusal wear

– Malocclusion (buccal, lingual, and interproximal surfaces)

Attrition




Wedge-shaped defects at the cementoenamel junction of a tooth caused by

eccentrically applied occlusal forces leading to tooth flexure that results in

microfracture of enamel and dentin.6

• Loss of tooth in the cervical area

– Tooth flexure

– Chewing

– Grinding (bruxism)

Abfraction




The physical results of a pathologic, chronic, localized loss of hard dental tissue that

is chemically etched away from the tooth surface by acid and/or chelation without

bacterial involvement.7

• Extrinsic acids — ingested

– Food, beverages, medicine

• Intrinsic acids — internal

– Originate in the stomach

Erosion




Tooth wear is multifactorial

• One process typically impacts the other

– Erosion and abrasion

Multifactorial




Tooth erosion was described as a condition distinct from caries as

early as the 18th century.8

Dental Erosion: Epidemiology



In 1995, the European Journal of Oral Science stated that ―dental erosion is an area of

research and clinical practice that will undoubtedly experience expansion in the next

decade.‖9

Change in Perception





Global Prevalence

Global data on the prevalence of dental erosion is building. ―Erosive tooth wear

is a common condition in the developed countries.‖10

United States

CanadaIceland

Ireland

Sweden

Germany

Turkey

Saudi Arabia

India

Brazil

Japan

Malaysia

Switzerland

The NetherlandsUK

China



• European studies suggest prevalence of:11-13

– Up to 50% if all preschool children

– Between 24% to 60% of school-aged children – As high as 82% in 18 to 88 years of age10

• Emerging prevalence studies providing data on gender, socio-economic status,

ethnic, and culture difference in addition to the age factor will prove to be invaluable

Global Prevalence




―Diagnosis is the intellectual course that integrates information obtained by clinical

examination of the teeth, use of diagnostic aids, conversation with the patient, and

biological knowledge. A proper diagnosis cannot be performed without inspection of the teeth and their immediate surroundings.‖14

Dental Erosion: Diagnosis



Dental Erosion—

Diagnosis

Check list to unveil etiological

factors for erosion15



Dental Erosion:

Diagnosis

Interaction of the different factors

for the development of erosive

tooth wear16,18

From: Lussi A. Dental Erosion: From Diagnosis to Therapy. Karger; 2006.




Clinical Appearance

There is no device available for the specific detection of dental erosion in routine practice.

Therefore, the clinical appearance is the most important feature for dental professionals

to diagnosis dental erosion.16



Dental Erosion—

Diagnosis

Tooth Wear—Clinical Appearance17



• Chemical factors — erosive potential of intrinsic and extrinsic acids

•Biological factors — involve properties and characteristics of the oral cavity

• Behavioral factors — personal and oral habits

Erosion is multifactorial




• pH and buffering capacity of the product

• Type of acid (pK a values)

–Intrinsic (gastric origin)

– Extrinsic (environmental, dietary, medicinal)

• Adhesion of the products to the dental surface

• Chelating properties of the products

• Calcium concentration

• Phosphate concentration

• Fluoride concentration

Chemical Factors18




• Saliva: flow rate, composition, buffering, capacity, and stimulation capacity

• Acquired pellicle: diffusion-limiting properties, composition, maturation, andthickness

• Type of dental substrate (permanent and primary enamel, dentin) and composition(eg, fluoride content as FHAp or CaF2-like particles)

• Dental anatomy and occlusion

• Anatomy of oral soft tissues in relationship to the teeth

• Physiologic soft tissue movements

Biological Factors19




• Unusual eating and drinking habits

• Healthy lifestyle: diets high in acidic fruits and vegetables

• Unhealthy lifestyle: frequent consumption of ―alcopops‖ and designer drugs• Alcoholic disease

• Excessive consumption of acidic foods and drinks

• Nighttime baby bottle feeding with acidic beverages, including milk

• Oral hygiene practices: frequent toothbrushing, abrasive oral care products

Behavioral Factors20




Loss of tooth surface is a multifactorial process and educationis the first step in the line of defense.4

Prevention




Dynamics of Dental Erosion21

Before During After

Time (Frequency)

Interactions between Behavioral and

Biological Factors

Dental Erosion: Diagnosis/Management

21. Lussi A, Kohler N, Zero D, et al.



Dental Erosion:

Management/Etiological Factors

Dietary factors15

• Avoid radical changes in dietary habits

• Reduce acid exposure by reducing frequency and contact time of

acid

• Avoid acidic foods and drinks late at night

• Avoid high-acidity liquids via baby bottle for infants

• Avoid low pH values in food and beverages

Awareness/Association/Education



Dental Erosion


Dietary factors: generally, a pH

value of 5.5 or lower is capable of

softening the surface of enamel

in only a few minutes.3


3. Strassler HE, Drisko CL, Alexander DC.



Dental Erosion:


Behavioral/habits15

• Do not hold or swish acidic drinks in your mouth

•Avoid sipping acidic drinks — use a straw

• Avoid toothbrushing immediately after an erosive challenge

(vomiting, acidic diet)

• Avoid toothbrushing immediately before an erosive challenge, as

the acquired pellicle provides protection against erosion

• Use a soft toothbrush




Dental Erosion:


Behavioral/Habits15

• Use a low-abrasion fluoride-containing toothpaste; high-abrasive

toothpaste may destroy pellicle

• Avoid toothpastes or mouthwashes with too-low pH

• After acid intake, stimulate saliva flow with chewing gum or

lozenges

• Use chewing gum to reduce postprandial reflux

• Refer patients or advise them to seek appropriate medical

attention when intrinsic causes are involved




Gastroesophageal Origin22

• Heartburn and other symptoms of reflux

• Regurgitation

• Dysphagia

• Asthma

• Rumination

• Eating disorders (anorexic or bulimia)

Dental Erosion:





Medicinal factors associated with dental erosion23

• Some medicines can potentially induce GERD – theophyline – progesterone – anti-asthmatics – calcium channel blockers

• Aspirin (especially in chewable format)

• Medicines that decrease salivary flow – antihistamines

– anticholinergics – antidepressants – antipsychotics


Dental Erosion:




Dental Erosion/Toothwear

Prevention is better than a cure… Education is the key!



References

1. Oral Health for Children: Patient Education Insert. Compend Contin Educ Dent. 2005;26(5 Suppl 1):Insert.

2. Sturdevant JR, Lundeen TF, Sluder TB Jr. Clinical significance of dental anatomy, histology, physiology, and occlusion. In: Robertson TM, Heymann HO,

Swift EJ Jr, eds. Sturdevant’s Art and Science of Operative Dentistry. 4th ed. Mosby: St. Louis, MO; 2002:13-61.

3. Strassler HE, Drisko CL, Alexander DC. Dentin hypersensitivity: its inter-relationship to gingival recession and acid erosion. Inside Dentistry. 2008;29(5

Special Issue):3-4.

4. Robertson TM, Lundeen TF. Cariology: the lesion, etiology, prevention, and control. In: Robertson TM, Heymann HO, Swift EJ Jr, eds. Sturdevant’s Art

and Science of Operative Dentistry. 4th ed. Mosby: St. Louis, MO; 2002:63-132.

5. Tooth Erosion in Children — US Perspective. Inside Dentistry. 2009;5(3 Suppl):8.

6. Imfeld T. Dental erosion. Definition, classification and links. Eur J Oral Sci. 1996;104(2 (Pt 2)):151-155.

7. ten Cate JM, Imfeld T. Dental erosion. Summary. Eur J Oral Sci. 1996;104(2 (Pt 2)):241-244.

8. The dental cosmos: a monthly record of dental science. Perioscope. 1875;17(2):93-109.

9. ten Cate JM, Imfeld T. Dental erosion. Preface. Eur J Oral Sci. 1996;104(2 (Pt 2)):149.

10. Jaeggi T, Lussi A. Prevalence, incidence, and distribution of erosion. In: Lussi A, ed. Dental Erosion: From Diagnosis to Therapy. Basel, Switzerland:

Karger; 2006:44-65. Whitford GM. Monographs in Oral Science; vol. 20.

11. Ganss C, Klimek J, Giese K. Dental erosion in children and adolescents: a cross-sectional and longitudinal investigation using study models. Community

Dent Oral Epidemiol. 2001;29(4):264-271.

12. Truin GJ, van Rijkom HM, Mulder J, van’t Hof MA. Caries trends 1996-2002 among 6- and 12-year-old children and erosive wear prevalence among 12-

year-old children in The Hague. Caries Res. 2005;39(1):2-8.

Dental Erosion/Tooth Wear—References



References

13. Dugmore CR, Rock WP. The prevalence of tooth erosion in 12-year-old children. Br Dent J. 2004;196(5):279-282.

14. Kidd EAM, Mejare L, Nyvad B. Clinical and radiographic diagnosis. In: Fejerskov O, Kidd EAM, eds. Dental Caries: The Disease and its Clinical

Management . Copenhagen: Blackwell Munksgaard; 2003:111-128.

15. Lussi A, Hellwig E. Risk assessment and preventative measures. In: Lussi A, ed. Dental Erosion: From Diagnosis to Therapy. Basel, Switzerland:

Karger; 2006:190-199. Whitford GM. Monographs in Oral Science; vol 20.

16. Lussi A. Erosive toothwear: a multifactorial condition of growing concern and increasing knowledge. In: Lussi A, ed. Dental Erosion: From

Diagnosis to Therapy. Basel, Switzerland: Karger; 2006:1-8. Whitford GM. Monographs in Oral Science; vol. 20.

17. Gandara BK, Truelove EL. Diagnosis and management of dental erosion. J Contemp Dent Pract . 1999;1(1):16-23.

18. Lussi A, Jaeggi T. Chemical factors. In: Lussi A, ed. Dental Erosion: From Diagnosis to Therapy. Basel, Switzerland: Karger; 2006:77-87. Whitford

GM. Monographs in Oral Science; vol. 20.

19. Hara AT, Lussi A, Zero DT. Biological factors. In: Lussi A, ed. Dental Erosion: From Diagnosis to Therapy. Basel, Switzerland: Karger; 2006:88-

91. Whitford GM. Monographs in Oral Science; vol 20.

20. Zero DT, Lussi A. Behavioral factors. In: Lussi A, ed. Dental Erosion: From Diagnosis to Therapy. Basel, Switzerland: Karger; 2006:100-105.

Whitford GM. Monographs in Oral Science; vol 20.

21. Lussi A, Kohler N, Zero D, et al. A comparison of the erosive potential of different beverages in primary and permanent teeth using an in vitro

model. Eur J Oral Sci. 2000;108(2):110-114.

22. Bartlett D. Intrinsic causes of erosion. In: Lussi A, ed. Dental Erosion: From Diagnosis to Therapy. Basel, Switzerland: Karger; 2006:119-139.Whitford GM. Monographs in Oral Science; vol 20.

23. Hellwig E, Lussi A. Oral hygiene products and acid medicines. In: Lussi A, ed. Dental Erosion: From Diagnosis to Therapy. Basel, Switzerland:

Karger; 2006:112-118. Whitford GM. Monographs in Oral Science; vol 20.

Dental Erosion/Tooth Wear—References



Dental Erosion—Tooth Wear

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