Risk assessment and preventive measures

A prerequisite for preventive measures is to diagnose erosive tooth wear and to evaluate the different etiological factors in order to identify persons at risk. No diagnostic device is available for the assessment of erosive defects. Thus, they can only be detected clinically. Consequently, erosion not diagnosed in the early stage may render timely preventive measures difficult. In order to assess the risk factors, patient should record their dietary intake for a distinct period of time. Then a dentist can determine the erosive potential of the diet. Particularly, patients with more than four dietary acid intakes have a higher risk for erosion when other risk factors (such as holding the drink in the mouth) are present. Regurgitation of gastric acids (reflux, vomiting, alcohol abuse, etc.) is a further important risk factor for the development of erosion which has to be taken into account. Based on these analyses, an individually tailored preventive program may be suggested to the patients. It may comprise dietary advice, optimization of fluoride regimes, stimulation of salivary flow rate, use of buffering medicaments and particular motivation for nondestructive toothbrushing habits with a low abrasive toothpaste. The frequent use of fluoride gel and fluoride solution in addition to fluoride toothpaste offers the opportunity to reduce somewhat abrasion of tooth substance. It is also advisable to avoid abrasive tooth cleaning and whitening products, since they may remove the pellicle and may render teeth more susceptible to erosion. Since erosion, attrition and abrasion often occur simultaneously all causative components must be taken into consideration when planning preventive strategies.

Extrinsic causes of erosion. Biological factors

Biological factors such as saliva, acquired dental pellicle, tooth structure and positioning in relation to soft tissues and tongue are related to dental erosion development. Saliva has been shown to be the most important biological factor in the prevention of dental erosion. It starts acting even before the acid attack, with the increase of the salivary flow rate as a response to the acidic stimuli. This creates a favorable scenario, increasing the buffering system of saliva and effectively diluting and clearing acids on dental surfaces during the erosive challenge. Saliva plays a role in the formation of the acquired dental pellicle, which acts as a perm-selective membrane preventing contact of the acid with the tooth surf aces. The protective level of the pellicle seems to be regulated by its composition, thickness and maturation time. Due to its mineral content, saliva can also prevent demineralization as well as enhance remineralization. However, these preventive and reparative factors of saliva may not be enough against highly erosive challenges, leading to erosion development. The progress rate of erosion can be significantly influenced by the type of dental substrate, occurrence of mechanical and chemical attacks, fluoride exposure, and also by contact with the oral soft tissues and tongue.

Extrinsic causes of erosion. Oral hygiene products and acidic medicines

Acidic or EDTA-containing oral hygiene products and acidic medicines have the potential to soften dental hard tissues. The low pH of oral care products increases the chemical stability of some fluoride compounds, favors the incorporation of fluoride ions in the lattice of hydroxyapatite and the precipitation of calcium fluoride on the tooth surface. This layer has some protective effect against an erosive attack. However, when the pH is too low or when no fluoride is present these protecting effects are replaced by direct softening of the tooth surface. Xerostomia or oral dryness can occur as a consequence of medication such as tranquilizers, anti-histamines, anti-emetics and anti-parkinsonian medicaments or of salivary gland dysfunction e.g. due to radiotherapy of the oral cavity and the head and neck region. Above all, these patients should be aware of the potential demineralization effects of oral hygiene products with low pH and high titratable acids. Acetyl salicylic acid taken regularly in the form of multiple chewable tablets or in the form of headache powder as well chewing hydrochloric acids tablets for treatment of stomach disorders can cause erosion. There is most probably no direct association between asthmatic drugs and erosion on the population level. Consumers, patients and health professionals should be aware of the potential of tooth damage not only by oral hygiene products and salivary substitutes but also by chewable and effervescent tablets. Additionally, it can be assumed that patients suffering from xerostomia should be aware of the potential effects of oral hygiene products with low pH and high titratable acids.

Extrinsic causes of erosion. Behavioral factors

During and after an erosive challenge, behavioral factors play a role in modifying the extent of erosive tooth wear. The manner that dietary acids are introduced into the mouth (gulping, sipping, use of a straw) will affect how long the teeth are in contact with the erosive challenge. The frequency and duration of exposure to an erosive agent is of paramount importance. Night-time exposure (e.g. baby bottle-feeding) to erosive agents may be particularly destructive because of the absence of salivary flow. Health-conscious individuals tend to ingest acidic drinks and juices more frequently and tend to have higher than average oral hygiene. While good oral hygiene is of proven value in the prevention of periodontal disease and dental caries, frequent toothbrushing with abrasive oral hygiene products may enhance erosive tooth wear. Unhealthy lifestyles such as consumption of designer drugs, alcopops and alcohol abuse are other important behavioral factors.

Erosion--diagnosis and risk factors

Dental erosion is a multifactorial condition: The interplay of chemical, biological and behavioural factors is crucial and helps explain why some individuals exhibit more erosion than others. The erosive potential of erosive agents like acidic drinks or foodstuffs depends on chemical factors, e.g. pH, titratable acidity, mineral content, clearance on tooth surface and on its calcium-chelation properties. Biological factors such as saliva, acquired pellicle, tooth structure and positioning in relation to soft tissues and tongue are related to the pathogenesis of dental erosion. Furthermore, behavioural factors like eating and drinking habits, regular exercise with dehydration and decrease of salivary flow, excessive oral hygiene and, on the other side, an unhealthy lifestyle, e.g. chronic alcoholism, are predisposing factors for dental erosion. There is some evidence that dental erosion is growing steadily. To prevent further progression, it is important to detect this condition as early as possible. Dentists have to know the clinical appearance and possible signs of progression of erosive lesions and their causes such that adequate preventive and, if necessary, therapeutic measures can be initiated. The clinical examination has to be done systematically, and a comprehensive case history should be undertaken such that all risk factors will be revealed.

Current erosion indices--flawed or valid? Summary

The problem of erosive tooth wear appears increasingly to be encountered by clinicians and researchers. An adequate way of defining and recording erosive tooth wear is essential in order to assess the extent of this clinical phenomenon, both on an individual level and in the population, and for the adequate provision of preventive and therapeutic measures. Well-established erosion indices have been used in most of these studies, although in many cases modifications have been made to suit the different research aims. This use of different indices is one reason why it still cannot be claimed that there is enough current knowledge on this clinical phenomenon. This article summarises the proceedings of a workshop to discuss the topic of dental erosion indices. The result of the workshop is the proposal for a new scoring system (Basic Erosive Wear Examination, BEWE) designed for use both within the research field and for dental clinicians, with the aims of standardising assessment of erosion for international comparisons, raising awareness and providing guidelines for treatment of erosive tooth wear in dental practice.

Impact of different toothpastes on the prevention of erosion

The aim of the present study was to test the impact of different toothpastes on the prevention of erosion. Enamel demineralization and remineralization were monitored using surface microhardness (SMH) measurements. Human enamel specimens were treated following two different procedures: (1) incubation in toothpaste slurry followed by acid softening and artificial saliva exposure; (2) acid softening followed by incubation in toothpaste slurry and artificial saliva exposure. For the control procedure, toothpaste treatment was excluded. The following toothpastes were tested: Zendium, Sensodyne Proschmelz (Pronamel), Prodent Rocket Power, Meridol and Signal active. Normalized SMH values compared to the baseline (= 1.00) after 1-hour artificial saliva exposure for procedure 1 (respectively for procedure 2) were as follows (mean: 95% CI): Sensodyne Proschmelz 0.97: 0.93, 1.00 (0.92: 0.90, 0.94), Zendium 0.97: 0.94, 1.00 (0.89: 0.83, 0.95), Meridol 0.97: 0.94, 1.00 (0.94: 0.92, 0.96), Signal active 0.94: 0.91, 0.97 (0.95: 0.91, 0.99), Prodent Rocket Power 0.92: 0.90, 0.94 (0.93: 0.89, 0.97) and control 0.91: 0.88, 0.94. Further exposure to artificial saliva for up to 4 h showed no significant improvement of SMH. Regression analyses revealed a significant impact of the applied procedure. Incubation in toothpaste slurries before the acid challenge seems to be favorable to prevent erosion. None of the tested toothpastes showed statistically significant better protection than another against an erosive attack.

Controlled toothbrush abrasion of softened human enamel

The aim of this in vitro study was to compare toothbrush abrasion of softened enamel after brushing with two (soft and hard) toothbrushes. One hundred and fifty-six human enamel specimens were indented with a Knoop diamond. Salivary pellicle was formed in vitro over a period of 3 h. Erosive lesions were produced by means of 1% citric acid. A force-measuring device allowed a controlled toothbrushing force of 1.5 N. The specimens were brushed either in toothpaste slurry or with toothpaste in artificial saliva for 15 s. Enamel loss was calculated from the change in indentation depth of the same indent before and after abrasion. Mean surface losses (95% CI) were recorded in ten treatment groups: (1) soft toothbrush only [28 (17-39) nm]; (2) hard toothbrush only [25 (16-34) nm]; (3) soft toothbrush in Sensodyne MultiCare slurry [46 (27-65) nm]; (4) hard toothbrush in Sensodyne MultiCare slurry [45 (24-66) nm]; (5) soft toothbrush in Colgate sensation white slurry [71 (55-87) nm]; (6) hard toothbrush in Colgate sensation white slurry [85 (60-110) nm]; (7) soft toothbrush with Sensodyne MultiCare [48 (39-57) nm]; (8) hard toothbrush with Sensodyne MultiCare [40 (29-51) nm]; (9) soft toothbrush with Colgate sensation white [51 (37-65) nm]; (10) hard toothbrush with Colgate sensation white [52 (36-68) nm]. Neither soft nor hard toothbrushes produced significantly different toothbrush abrasion of softened human enamel in this model (p > 0.05).

Comparison of calcium analysis, longitudinal microradiography and profilometry for the quantitative assessment of erosion in dentine

Erosion of dentine causes mineral dissolution, while the organic compounds remain at the surface. Therefore, a determination of tissue loss is complicated. Established quantitative methods for the evaluation of enamel have also been used for dentine, but the suitability of these techniques in this field has not been systematically determined. Therefore, this study aimed to compare longitudinal microradiography (LMR), contacting (cPM) and non-contacting profilometry (ncPM), and analysis of dissolved calcium (Ca analysis) in the erosion solution. Results are discussed in the light of the histology of dentine erosion. Erosion was performed with 0.05 M citric acid (pH 2.5) for 30, 60, 90 or 120 min, and erosive loss was determined by each method. LMR, cPM and ncPM were performed before and after collagenase digestion of the demineralised organic surface layer, with an emphasis on moisture control. Scanning electron microscopy was performed on randomly selected specimens. All measurements were converted into micrometres. Profilometry was not suitable to adequately quantify mineral loss prior to collagenase digestion. After 120 min of erosion, values of 5.4 +/- 1.9 microm (ncPM) and 27.8 +/- 4.6 microm (cPM) were determined. Ca analysis revealed a mineral loss of 55.4 +/- 11.5 microm. The values for profilometry after matrix digestion were 43.0 +/- 5.5 microm (ncPM) and 46.9 +/- 6.2 (cPM). Relative and proportional biases were detected for all method comparisons. The mineral loss values were below the detection limit for LMR. The study revealed gross differences between methods, particularly when demineralised organic surface tissue was present. These results indicate that the choice of method is critical and depends on the parameter under study.

Buonocore Memorial Lecture. Dental erosion

There is some evidence that dental erosion is steadily spreading. To diagnose erosion, dental professionals have to rely on clinical appearance, as there is no device available to detect it. Adequate preventive measures can only be initiated if the different risk factors and potential interactions between them are known. When substance loss, caused by erosive tooth wear, reaches a certain degree, oral rehabilitation becomes necessary. Prior to the most recent decade, the severely eroded dentition could only be rehabilitated by the provision of extensive crown and bridgework or removable dentures. As a result of the improvements in composite restorative materials and in adhesive techniques, it has become possible to rehabilitate eroded dentitions in a less invasive manner.

Erosion Damage Mapping: Assessing Current Soil Erosion Damage in Switzerland

Within the scope of a comprehensive assessment of the degree of soil erosion in Switzerland, common methods have been used in the past including test plot measurements, artificial rainfall simulation, and erosion modelling. In addition, mapping guidelines for all visible erosion features have been developed since the 1970s and are being successfully applied in many research and soil conservation projects. Erosion damage has been continuously mapped over a period of 9 years in a test region in the central Bernese plateau. In 2005, two additional study areas were added. The present paper assesses the data gathered and provides a comparison of the three study areas within a period of one year (from October 2005 to October 2006), focusing on the on-site impacts of soil erosion. During this period, about 11 erosive rainfall events occurred. Average soil loss rates mapped at each study site amounted to 0.7 t ha-1, 1.2 t ha-1 and 2.3 t ha-1, respectively. About one fourth of the total arable land showed visible erosion damage. Maximum soil losses of about 70 t ha-1 occurred on individual farm plots. Average soil erosion patterns are widely used to underline the severity of an erosion problem (e.g. impacts on water bodies). But since severe rainfall events, wheel tracks, headlands, and other “singularities” often cause high erosion rates, analysis of extreme erosion patterns such as maximum values led to a more differentiated understanding and appropriate conclusions for planning and design of soil protection measures. The study contains an assessment of soil erosion in Switzerland, emphasizing questions about extent, frequency and severity. At the same time, the effects of different types of land management are investigated in the field, aiming at the development of meaningful impact indicators of (un-)sustainable agriculture/soil erosion risk as well as the validation of erosion models. The results illustrate that conservation agriculture including no-till, strip tillage and in-mulch seeding plays an essential role in reducing soil loss as compared to conventional tillage.

The effect of a tin-containing fluoride mouth rinse on the bond between resin composite and erosively demineralised dentin

OBJECTIVES To evaluate the effect of a tin-containing fluoride (Sn/F) mouth rinse on microtensile bond strength (μTBS) between resin composite and erosively demineralised dentin. MATERIALS AND METHODS Dentin of 120 human molars was erosively demineralised using a 10-day cyclic de- and remineralisation model. For 40 molars, the model comprised erosive demineralisation only; for another 40, the model included treatment with a NaF solution; and for yet another 40, the model included treatment with a Sn/F mouth rinse. In half of these molars (n = 20), the demineralised organic matrix was continuously removed by collagenase. Silicon carbide paper-ground, non-erosively demineralised molars served as control (n = 20). Subsequently, μTBS of Clearfil SE/Filtek Z250 to the dentin was measured, and failure mode was determined. Additionally, surfaces were evaluated using SEM and EDX. RESULTS Compared to the non-erosively demineralised control, erosive demineralisation resulted in significantly lower μTBS regardless of the removal of demineralised organic matrix. Treatment with NaF increased μTBS, but the level of μTBS obtained by the non-erosively demineralised control was only reached when the demineralised organic matrix had been removed. The Sn/F mouth rinse together with removal of demineralised organic matrix led to significantly higher µTBS than did the non-erosively demineralised control. The Sn/F mouth rinse yielded higher μTBS than did the NaF solution. CONCLUSIONS Treatment of erosively demineralised dentin with a NaF solution or a Sn/F mouth rinse increased the bond strength of resin composite. CLINICAL RELEVANCE Bond strength of resin composite to eroded dentin was not negatively influenced by treatment with a tin-containing fluoride mouth rinse.

Effects of buffering properties and undissociated acid concentration on dissolution of dental enamel in relation to pH and acid type

To quantify the relationships between buffering properties and acid erosion and hence improve models of erosive potential of acidic drinks, a pH-stat was used to measure the rate of enamel dissolution in solutions of citric, malic and lactic acids, with pH 2.4-3.6 and with acid concentrations adjusted to give buffer capacities (β) of 2-40 (mmol·l(-1))·pH(-1) for each pH. The corresponding undissociated acid concentrations, [HA], and titratable acidity to pH 5.5 (TA5.5) were calculated. In relation to β, the dissolution rate and the strength of response to β varied with acid type (lactic > malic ≥ citric) and decreased as pH increased. The patterns of variation of the dissolution rate with TA5.5 were qualitatively similar to those for β, except that increasing pH above 2.8 had less effect on dissolution in citric and malic acids and none on dissolution in lactic acid. Variations of the dissolution rate with [HA] showed no systematic dependence on acid type but some dependence on pH. The results suggest that [HA], rather than buffering per se, is a major rate-controlling factor, probably owing to the importance of undissociated acid as a readily diffusible source of H(+) ions in maintaining near-surface dissolution within the softened layer of enamel. TA5.5 was more closely correlated with [HA] than was β, and seems to be the preferred practical measure of buffering. The relationship between [HA] and TA5.5 differs between mono- and polybasic acids, so a separate analysis of products according to predominant acid type could improve multivariate models of erosive potential.

Prevalence of tooth wear on buccal and lingual surfaces and possible risk factors in young European adults

To assess the prevalence of tooth wear on buccal/facial and lingual/palatal tooth surfaces and identify related risk factors in a sample of young European adults, aged 18-35 years. Calibrated and trained examiners measured tooth wear, using the basic erosive wear examination (BEWE) on in 3187 patients in seven European countries and assessed the impact of risk factors with a previously validated questionnaire. Each individual was characterized by the highest BEWE score recorded for any scoreable surface. Bivariate analyses examined the proportion of participants who scored 2 or 3 in relation to a range of demographic, dietary and oral care variables. The highest tooth wear BEWE score was 0 for 1368 patients (42.9%), 1 for 883 (27.7%), 2 for 831 (26.1%) and 3 for 105 (3.3%). There were large differences between different countries with the highest levels of tooth wear observed in the UK. Important risk factors for tooth wear included heartburn or acid reflux, repeated vomiting, residence in rural areas, electric tooth brushing and snoring. We found no evidence that waiting after breakfast before tooth brushing has any effect on the degree of tooth wear (p=0.088). Fresh fruit and juice intake was positively associated with tooth wear. In this adult sample 29% had signs of tooth wear making it a common presenting feature in European adults.

Prevalence of dentine hypersensitivity and study of associated factors: a European population-based cross-sectional study

OBJECTIVES Dentine hypersensitivity (DH) manifests as a transient but arresting oral pain. The incidence is thought to be rising, particularly in young adults, due to increases in consumption of healthy, yet erosive, diets. This study aimed to assess the prevalence of DH and relative importance of risk factors, in 18-35 year old Europeans. METHODS In 2011, 3187 adults were enrolled from general dental practices in France, Spain, Italy, United Kingdom, Finland, Latvia and Estonia. DH was clinically evaluated by cold air tooth stimulation, patient pain rating (yes/no), accompanied by investigator pain rating (Schiff 0-3). Erosive toothwear (BEWE index 0-3) and gingival recession (mm) were recorded. Patients completed a questionnaire regarding the nature of their DH, erosive dietary intake and toothbrushing habits. RESULTS 41.9% of patients reported pain on tooth stimulation and 56.8% scored ≥1 on Schiff scale for at least one tooth. Clinical elicited sensitivity was closely related to Schiff score and to a lesser degree, questionnaire reported sensitivity (26.8%), possibly reflecting the transient nature of the pain, alongside good coping mechanisms. Significant associations were found between clinically elicited DH and erosive toothwear and gingival recession. The questionnaire showed marked associations between DH and risk factors including heartburn/acid reflux, vomiting, sleeping medications, energy drinks, smoking and acid dietary intake. CONCLUSION Overall, the prevalence of DH was high compared to many published findings, with a strong, progressive relationship between DH and erosive toothwear, which is important to recognise for patient preventive therapies and clinical management of DH pain.