Managing Dental Erosive Tooth Wear: Current Understanding and Future Directions
Course Number: 517
The dental research community has made great strides in preventive dentistry over the past several decades, with breakthroughs such as the introduction of fluoride and tartar control dentifrices, enhanced dentin hypersensitivity reduction approaches and fluoride varnishes. In spite of these advances, dental erosive tooth wear has become a major new challenge for dental professionals. First identified as an emerging issue approximately 30 years ago, the prevalence of erosive tooth wear is increasing, the current estimated global prevalence in children and adolescents is 30-50%, and 20-45% among adults.1 This is of particular concern since the enamel and dentin loss associated with this multifactorial condition is irreversible.
Historically there has been confusion between dental caries and erosive toothwear in the primary dentition as early clinical lesions can look alike. Despite some similarities between dental erosive toothwear and dental caries they are two unique processes with critical differences related to the etiological factors, the long-term effects, and the best ways to help manage these issues for each patient. They are both however, noncommunicable diseases (NCDs) and are highlighted by the World Health Organization to have major impact on health, well-being, health care systems and economies, adding to the increasing burden of NCDs. Challenges across all countries are related to inequalities, linked to exposure to risk factors like high sugar consumption and tobacco or alcohol use as well as to wider social, commercial and political determinants of oral health. Recognition of oral diseases as a global public health problem will continue to generate momentum, and action with ambitious targets to be achieved by 2030 through primary health care, there is hope that substantial progress will be made globally to close the gaps in oral health.2
Dental erosion is a condition that results from an excessive exposure to erosive acids, either of extrinsic (dietary) or intrinsic (gastric) origin. First quantified on a wide scale basis in the United Kingdom,3,4 and also throughout Europe,5-9 this problem later gained significant interest on a more global scale.10,11 This condition is highly relevant to oral health professionals, and it presents these professionals with challenges regarding its detection, prevention and management. From a patient's point of view, dental erosive tooth wear can be associated with esthetic problems and pain from dentin hypersensitivity. It can also impact long-term tooth function. From the oral health care professional's point of view, it can be very difficult to manage; frequently requiring patient behavior change which can present a significant hurdle along with complex restorative treatment and long term monitoring and maintenance.
In most cases, dental erosion does not present as a single condition. It is one part of a broader, multi-factorial ‘umbrella’ condition referred to as erosive tooth wear (ETW) (Figure 1). ETW is a growing problem, seen day to day in general practice (Figure 2). It includes different factors, including dental erosive tooth wear, abrasion and attrition, alone or in combination. Generally, ETW is classified according to the specific mechanism that is responsible for the wear. While the mechanism for tooth wear resulting from erosion is chemical, abrasion and attrition are the result of physical forces. Abfraction, a theoretical term cited in the literature as a fourth type of tooth wear etiology, has been discouraged as a used term, recent consensus meetings and publications determined that there is not enough evidence to support this as a separate process.12,13
In the past, particularly in the US, dental professionals often associated tooth wear with occlusion and bruxism. But the fact is it probably has more to do with acid impact on teeth. Changes on the lingual surfaces of eroded teeth, for example, are likely the result of a combination of acid and repetitive, frictional forces from the tongue.14 It is not from occlusion or any type of a bruxism-type movement. There are two distinct processes at work, which highlights the complexity of the problem. Regardless of which forces are at play in an individual patient, the net clinical outcome is tooth surface loss.
Figure 1. Erosive Tooth Wear (ETW) is an umbrella term that includes dental erosion, attrition and abrasion, alone or in combination.
Figure 2. Severe erosion on a patient consuming 1.5 gallons of Kombucha tea, a low pH fermented drink, daily.
Dental erosion is an outcome resulting from the dissolution of dental hard tissue by either intrinsic or extrinsic acids that are not of biological origin.
Abrasion is a form of physical wear that is the result of mechanical interactions, such as tooth brushing or repetitive contact of a foreign object, with opposing tooth surfaces.
Attrition is a form of physical wear that occurs as the result of one tooth coming into contact with another and is often associated with bruxism (unconscious tooth grinding or clenching).
Clinically, ETW is often associated with a combination of tooth wear processes, with dental erosion being the most common component. In addition, dental hygiene habits, such as brushing with a hard-bristled toothbrush or brushing too soon after taking in acid-containing food or beverages, can have an impact on tooth wear. Excessive tooth brushing can also remove significant portions of the acquired dental pellicle. Pellicle serves as a natural protection against both erosive acids and frictional wear. When teeth are brushed directly before eating or drinking, the thickness of the pellicle, and therefore its ability to protect exposed tooth surfaces, is reduced. Soon after brushing, the pellicle begins to be restored. Many dental professionals now suggest waiting for 1-2 hours after brushing before consuming acid-containing foods and beverages,15 giving the pellicle sufficient time to regain a reasonable level of defense.
As we are all aware, people are living longer. Our medical colleagues recommend that we eat more fresh fruit and vegetables, which is sometimes a more erosive diet, in order to combat certain diseases, such as diabetes and cardiovascular disease. In addition, our consumption of acidic soft drinks is increasing dramatically year-on-year. Data comparing populations in both the UK and US suggest we can anticipate finding a significant level of dental erosion in the general population,16 with even higher numbers anticipated for specific high risk groups.4,6,17 The evidence suggests the presence of erosion is growing steadily.5,18 A recent 7 year study involving over 3500 people across 7 European countries showed that the maximum BEWE 1 score is particularly high in young adults indicating ETW is initiated in adolescence or younger. Patients presenting with ETW should have their dietary habits assessed by recording their complete dietary intake in a diet record, from which clinicians can assess the erosive potential of the different beverages and foods, as well as the frequency of ingestion, to provide individually tailored prevention and intervention.19
There has been a significant decline in the prevalence of edentulism reported at global, regional and country levels. The global estimated prevalence of edentulism was 22%, with 11% (North America), 28% (Europe), and 37% (South America).20 A growing older population who are retaining more teeth present additional challenges for clinicians as many of these patients are aesthetically sensitive. In the past, people in this cohort had a greater acceptance of extractions and dentures however this is changing, and we have far more teeth needing attention than we did several years ago. The change in appearance of worn teeth does not necessitate the need for restorative intervention, but for some the rate of wear or severity becomes so pronounced that treatment should be considered,21 this needs to be acknowledged and properly managed.
It is not unreasonable to surmise that the increasing life expectancy, coupled with maintaining a healthier lifestyle involving a more acidic diet, may well lead to more and more cases of dental erosion. That is, of course, unless we put preventative measures in place to help address these concerns before significant damage is caused. Dental professionals need to be far more proactive at looking for erosion, particularly at the earliest stages of the condition, and recommending the use of products that have been demonstrated to be effective at helping to prevent its initiation and progression.