Medical conditions: Some medical conditions expose the teeth to frequent and repeated direct contact with gastric contents, the pH of which can be as low as 1, so its destructive capabilities are especially severe. Conditions such as chronic vomiting in eating disorders such as anorexia and bulimia nervosa, passive regurgitation in gastro-esophageal reflux disease (GERD) and chronic alcoholism and binge drinking, have all been associated with ETW.9 GERD are likely to be more destructive due to decrease in salivary flow during sleep.10
Misuse of acidic dietary products: Frequent and prolonged ingestion of acidic fruit juices and acidic beverages (alcohol, herbal teas, energy drinks) as observed in situations like habitual intake, dieting with citrus fruits and fruit juices, and drinking during strenuous sporting activities, have been associated with ETW.11 These practices would lower the pH of the oral fluids for a prolonged period, thus exposing the teeth to prolonged period of acidic challenge with consequent dissolution of the mineralized tooth tissue. Especially problematic is the habit of swishing soda in the mouth to prevent the uncomfortable sensation of carbonation in the throat. This habit enhances the dissolution process because the solution on the surface layer adjacent to tooth mineral will be readily renewed.
Use of acidic medicaments and illegal drugs: Some medicaments such as acetylsalicylic acid, ascorbic acid, liquid hydrochloric acid, iron tonics, and acidic saliva stimulants/substitutes prescribed for frequent intake for long periods of time have the potential to soften dental hard tissues, and as such have high erosive potentials.12,13 Addictive use of certain illegal drugs like cocaine and ecstasy have the side-effects of dehydration and hyposalivation, leading excessive consumption of acidic beverages by the users, thus predisposing these individuals to the risk of ETW.13
Low pH Toothpastes and Mouthrinses: Some oral care products such as toothpastes and mouthrinses exhibit pH values as low as 3.4. The acidic nature of these products is intended to enhance the chemical stability of some compounds but may also enhance the incorporation of fluoride ions in tooth mineral forms, as well as the precipitation of calcium fluoride on the tooth surface.13 However, when tested under more clinically relevant conditions, all these products caused progressive enamel surface loss over time, similar to that of an orange juice, thus indicating these oral care products to be a risk factor for ETW.14
Occupation: Certain industrial processing procedures expose the workers to acidic fumes or aerosols as observed in battery and fertilizer factories, professional swimming in improperly pH-regulated swimming pools, and professional wine tasting, have all been linked to ETW.12,15-17
