Background

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 sensitivity reduction approaches and fluoride varnishes. In spite of these advances, dental erosion has become a major new challenge for dental professionals. First identified as an emerging issue approximately 25 years ago, the prevalence of dental erosion has increased dramatically in children, adolescents and adults ever since. This is of particular concern since the enamel and dentin loss associated with this multifactorial condition is irreversible.

Confusion exists, however, regarding the differences between dental erosion and dental caries. Although there are some similarities between these two unique processes, there are critical differences related to the etiological factors, the long-term effects, and the best ways to help manage these issues for each patient.

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,^1,2 and also throughout Europe,^3-7 this problem later gained significant interest on a more global scale.^8,9 This condition is highly relevant to oral health professionals, and it presents these professionals with challenges regarding its treatment. From a patient's point of view, dental erosion 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 the condition; it sometimes requires changes in patient habits, which can present a significant hurdle.

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 erosion, abfraction, 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, abfraction, abrasion and attrition are the result of physical forces.

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. 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.¹⁰ 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.

Figure 1.

Erosive Tooth Wear (ETW) is an umbrella term that includes dental erosion, abfraction, attrition and abrasion, alone or in combination.

Figure 2.

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.

• Abfraction is a form of physical wear along the gingival margin that is not caused by bacterial acid activity.

• 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 (tooth grinding).

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,¹¹ giving the pellicle sufficient time to regain a reasonable level of defense.

As we are all aware, people are living longer. If we were born today, our average life expectancy might be 100 years of age. 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,¹² with even higher numbers anticipated for specific high risk groups.^2,4,13 The evidence suggests the presence of erosion is growing steadily.^8,14 A recent study in Europe showed that 30% of young adults, 18-35 year olds, had dental erosion, much of which may be attributed to excessive consumption of soft drinks.¹⁵

‘Baby Boomers’ can represent a large patient population in many dental practices. These patients are much different than their similar age counterparts from 20-40 years ago. Patients now live longer, keep their teeth longer, and they're more physically active. Many of them are aesthetically sensitive, with different kinds of demands; they’re not willing to settle for extractions and dentures. In fact, edentulism rates in the United States have decreased significantly in this age group, from about 45% in 1974 to just under 11% now.¹⁶ This means that, for these patients in particular, we have far more teeth needing attention than we did several years ago. 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. As a start, 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.