Influence of human saliva on the development of artificial erosions

It was hypothesized that saliva from patients with erosion exhibits lower protective efficacy compared to saliva from patients without erosion, based on in vitro enamel softening studies. A total of 645 enamel specimens were distributed among seven experimental groups. Saliva was gathered from each of 10 volunteers without clinical signs of dental erosion and from 10 patients exhibiting severe erosive defects. Aliquots of 50 ml of saliva from each patient were mixed with sour drops or citric acid, respectively. Pooled saliva, sour drops and citric acid mixed with water served as controls. The enamel specimens were soaked in the respective mixture for 5 min and were subsequently incubated in pure saliva for 2 min. This cycle was repeated three times, then the specimens were kept in 100 ml of saliva for 8 h. Surface microhardness was evaluated at the beginning of the experiment and after each cycle. During the experiments, microhardness decreased significantly in all groups except for the pure saliva group. For sour drops and citric acid mixed with saliva from patients without erosion, the final microhardness was higher compared to the mixture of the two erosive compounds with saliva from patients with erosion. The storage of saliva for 8 h resulted in a certain amount of rehardening, with the highest level of rehardening being observed in the group that was least demineralized (sour drops plus saliva from patients without erosion). It is concluded that salivary components play a crucial role in the development of dental erosion.

[The stamp technique for direct composite restoration]

The indications for direct resin composite restorations are nowadays extended due to the development of modern resin materials with improved material properties. However, there are still some difficulties regarding handling of resin composite material, especially in large restorations. The reconstruction of a functional and individual occlusion is difficult to achieve with direct application techniques. The aim of the present publication was to introduce a new "stamp"-technique for placing large composite restorations. The procedure of this "stamp"-technique is presented by three typical indications: large single-tooth restoration, occlusal rehabilitation of a compromised occlusal surface due to erosions and direct fibre-reinforced fixed partial denture. A step-by-step description of the technique and clinical figures illustrates the method. Large single-tooth restorations can be built-up with individual, two- piece silicone stamps. Large occlusal abrasive and/or erosive defects can be restored by copying the wax-up from the dental technician using the "stamp"-technique. Even fiber-reinforced resin-bonded fixed partial dentures can be formed with this intraoral technique with more precision and within a shorter treatment time. The presented "stamp"-technique facilitates the placement of large restoration with composite and can be recommended for the clinical use.

A new optical detection method to assess the erosion inhibition by in vitro salivary pellicle layer

OBJECTIVES Application of the recently developed optical method based on the monitoring of the specular reflection intensity to study the protective potential of the salivary pellicle layer against early enamel erosion. METHODS The erosion progression was compared between two treatment groups: enamel samples coated by the 15 h-in vitro-formed salivary pellicle layer (group P, n=90) and the non-coated enamel surfaces (control group C, n=90). Different severity of the erosive impact was modelled by the enamel incubation in 1% citric acid (pH=3.6) for 2, 4, 8, 10 or 15 min. Erosion quantification was performed by the optical method as well as by the microhardness and calcium release analyses. RESULTS Optical assessment of the erosion progression showed erosion inhibition by the in vitro salivary pellicle in short term acidic treatments (≤ 4 min) which was also confirmed by microhardness measurements proving significantly less (p<0.05) enamel softening in the group P at 2 and 4 min of erosion compared to the group C. SEM images demonstrated less etched enamel interfaces in the group P at short erosion durations as well. CONCLUSIONS Monitoring of the specular reflection intensity can be successfully applied to quantify early erosion progression in comparative studies. In vitro salivary pellicle (2h) provides erosion inhibition but only in short term acidic exposures. CLINICAL SIGNIFICANCE The proposed optical technique is a promising tool for the fast and non-invasive erosion quantification in clinical studies.

The effect of monoalkyl phosphates and fluoride on dissolution of hydroxyapatite, and interactions with saliva

The aims were to investigate the effect of monoalkyl phosphates (MAPs) and fluoride on dissolution rate of native and saliva-coated hydroxyapatite (HA). Fluoride at 300 mg/l (as NaF) inhibited dissolution of native HA by 12%, while potassium and sodium dodecyl phosphates (PDP, SDP), at 0.1% or higher, inhibited dissolution by 26-34%. MAPs, but not fluoride, also showed persistence of action. MAPs at 0.5% and fluoride at 300 mg/l were then tested separately against HA pre-treated with human saliva for 2 or 18 h. Agents were applied with brushing to half the specimens, and without brushing to the other half. In control (water-treated) specimens, pre-treatment of HA with human saliva reduced dissolution rate on average by 41% (2 h) and 63% (18 h). Brushing did not have a statistically significant effect on dissolution rate of saliva-coated specimens. In brushed specimens, fluoride significantly increased the inhibition due to 2- or 18-hour saliva pre-treatment. It is hypothesised that brushing partially removes the salivary film and allows KOH-soluble calcium fluoride formation at the surfaces of HA particles. Inhibition was reduced by PDP in 2-hour/non-brushed specimens and in 18-hour/brushed specimens. PDP did not affect dissolution rates in the remaining groups and SDP did not affect dissolution rate in any group. Possible reasons for these variable results are discussed. The experiments show that pre-treatment with saliva can significantly modify results of tests on potential anti-erosive agents and it is recommended that saliva pre-treatment should be a routine part of testing such agents.

Anaemia may add information to standardised disease activity assessment to predict radiographic damage in rheumatoid arthritis: a prospective cohort study

OBJECTIVE: Anaemia in rheumatoid arthritis (RA) is prototypical of the chronic disease type and is often neglected in clinical practice. We studied anaemia in relation to disease activity, medications and radiographic progression. METHODS: Data were collected between 1996 and 2007 over a mean follow-up of 2.2 years. Anaemia was defined according to WHO (♀ haemoglobin<12 g/dl, ♂: haemoglobin<13 g/dl), or alternative criteria. Anaemia prevalence was studied in relation to disease parameters and pharmacological therapy. Radiographic progression was analysed in 9731 radiograph sets from 2681 patients in crude longitudinal regression models and after adjusting for potential confounding factors, including the clinical disease activity score with the 28-joint count for tender and swollen joints and erythrocyte sedimentation rate (DAS28ESR) or the clinical disease activity index (cDAI), synthetic antirheumatic drugs and antitumour necrosis factor (TNF) therapy. RESULTS: Anaemia prevalence decreased from more than 24% in years before 2001 to 15% in 2007. Erosions progressed significantly faster in patients with anaemia (p<0.001). Adjusted models showed these effects independently of clinical disease activity and other indicators of disease severity. Radiographic damage progression rates were increasing with severity of anaemia, suggesting a 'dose-response effect'. The effect of anaemia on damage progression was maintained in subgroups of patients treated with TNF blockade or corticosteroids, and without non-selective nonsteroidal anti-inflammatory drugs (NSAIDs). CONCLUSIONS: Anaemia in RA appears to capture disease processes that remain unmeasured by established disease activity measures in patients with or without TNF blockade, and may help to identify patients with more rapid erosive disease.

Paleo erosion rates and climate shifts recorded by Quaternary cut-and-fill sequences in the Pisco valley, central Peru

Fluvial cut-and-fill sequences have frequently been reported from various sites on Earth. Nevertheless, the information about the past erosional regime and hydrological conditions have not yet been adequately deciphered from these archives. The Quaternary terrace sequences in the Pisco valley, located at ca. 13°S, offer a manifestation of an orbitally-driven cyclicity in terrace construction where phases of sediment accumulation have been related to the Minchin (48–36 ka) and Tauca (26–15 ka) lake level highstands on the Altiplano. Here, we present a 10Be-based sediment budget for the cut-and-fill terrace sequences in this valley to quantify the orbitally forced changes in precipitation and erosion. We find that the Minchin period was characterized by an erosional pulse along the Pacific coast where denudation rates reached values as high as 600±80 mm/ka600±80 mm/ka for a relatively short time span lasting a few thousands of years. This contrasts to the younger pluvial periods and the modern situation when 10Be-based sediment budgets register nearly zero erosion at the Pacific coast. We relate these contrasts to different erosional conditions between the modern and the Minchin time. First, the sediment budget infers a precipitation pattern that matches with the modern climate ca. 1000 km farther north, where highly erratic and extreme El Niño-related precipitation results in fast erosion and flooding along the coast. Second, the formation of a thick terrace sequence requires sufficient material on catchment hillslopes to be stripped off by erosion. This was most likely the case immediately before the start of the Minchin period, because this erosional epoch was preceded by a >50 ka-long time span with poorly erosive climate conditions, allowing for sufficient regolith to build up on the hillslopes. Finally, this study suggests a strong control of orbitally and ice sheet forced latitudinal shifts of the ITCZ on the erosional gradients and sediment production on the western escarpment of the Peruvian Andes at 13° during the Minchin period.

Water versus ice: The competing roles of modern climate and Pleistocene glacial erosion in the Central Alps of Switzerland

Recent studies have identified relationships between landscape form, erosion and climate in regions of landscape rejuvenation, associated with increased denudation. Most of these landscapes are located in non-glaciated mountain ranges and are characterized by transient geomorphic features. The landscapes of the Swiss Alps are likewise in a transient geomorphic state as seen by multiple knickzones. In this mountain belt, the transient state has been related to erosional effects during the Late Glacial Maximum (LGM). Here, we focus on the catchment scale and categorize hillslopes based on erosional mechanisms, landscape form and landcover. We then explore relationships of these variables to precipitation and extent of LGM glaciers to disentangle modern versus palaeo controls on the modern shape of the Alpine landscape. We find that in grasslands, the downslope flux of material mainly involves unconsolidated material through hillslope creep, testifying a transport-limited erosional regime. Alternatively, strength-limited hillslopes, where erosion is driven by bedrock failure, are covered by forests and/or expose bedrock, and they display oversteepened hillslopes and channels. There, hillslope gradients and relief are more closely correlated with LGM ice occurrence than with precipitation or the erodibility of the underlying bedrock. We relate the spatial occurrence of the transport- and strength-limited process domains to the erosive effects of LGM glaciers. In particular, strength-limited, rock dominated basins are situated above the equilibrium line altitude (ELA) of the LGM, reflecting the ability of glaciers to scour the landscape beyond threshold slope conditions. In contrast, transport-limited, soil-mantled landscapes are common below the ELA. Hillslopes covered by forests occupy the elevations around the ELA and are constrained by the tree line. We conclude that the current erosional forces at work in the Central Alps are still responding to LGM glaciation, and that the modern climate has not yet impacted on the modern landscape.

Risk assessment and causal 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 at an early stage may render timely preventive measures difficult. In order to assess the risk factors, patients should record their dietary intake for a distinct period of time. Then a dentist can determine the erosive potential of the diet. A table with common beverages and foodstuffs is presented for judging the erosive potential. Particularly, patients with more than 4 dietary acid intakes have a higher risk for erosion when other risk factors are present. Regurgitation of gastric acids 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, use of calcium-enriched beverages, optimization of prophylactic regimes, stimulation of salivary flow rate, use of buffering medicaments and particular motivation for nondestructive toothbrushing habits with an erosive-protecting toothpaste as well as rinsing solutions. Since erosion and abrasion often occur simultaneously, all of the causative components must be taken into consideration when planning preventive strategies but only those important and feasible for an individual should be communicated to the patient.

Understanding the chemistry of dental erosion.

Dental erosion is caused by repeated short episodes of exposure to acids. Dental minerals are calcium-deficient, carbonated hydroxyapatites containing impurity ions such as Na(+), Mg(2+) and Cl(-). The rate of dissolution, which is crucial to the progression of erosion, is influenced by solubility and also by other factors. After outlining principles of solubility and acid dissolution, this chapter describes the factors related to the dental tissues on the one hand and to the erosive solution on the other. The impurities in the dental mineral introduce crystal strain and increase solubility, so dentine mineral is more soluble than enamel mineral and both are more soluble than hydroxyapatite. The considerable differences in structure and porosity between dentine and enamel influence interactions of the tissues with acid solutions, so the relative rates of dissolution do not necessarily reflect the respective solubilities. The rate of dissolution is further influenced strongly by physical factors (temperature, flow rate) and chemical factors (degree of saturation, presence of inhibitors, buffering, pH, fluoride). Temperature and flow rate, as determined by the method of consumption of a product, strongly influence erosion in vivo. The net effect of the solution factors determines the overall erosive potential of different products. Prospects for remineralization of erosive lesions are evaluated.

Oral hygiene products, medications and drugs - hidden aetiological factors for dental erosion.

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 and favours 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. Oral dryness can occur as a consequence of medication such as tranquilizers, antihistamines, antiemetics and antiparkinsonian medicaments or of salivary gland dysfunction. Above all, patients should be aware of the potential demineralization effects of oral hygiene products with low pH. Acetyl salicylic acid taken regularly in the form of multiple chewable tablets or in the form of headache powder, as well as chewing hydrochloric acids tablets for the treatment of stomach disorders, can cause erosion. There is most probably no direct association between asthmatic drugs and erosion on the population level. Consumers 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. Several paediatric medications show a direct erosive potential in vitro. Clinical proof of the occurrence of erosion after use of these medicaments is still lacking. However, regular and prolonged use of these medicaments might bear the risk of causing erosion. 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 acidity.

Erosion in relation to nutrition and the environment.

When considering the erosive potential of a food or drink, a number of factors must be taken into account. pH is arguably the single most important parameter in determining the rate of erosive tissue dissolution. There is no clear-cut critical pH for erosion as there is for caries. At low pH, it is possible that other factors are sufficiently protective to prevent erosion, but equally erosion can progress in acid of a relatively high pH in the absence of mitigating factors. Calcium and phosphate concentration, in combination with pH, determine the degree of saturation with respect to tooth minerals. Solutions supersaturated with respect to enamel or dentine will not cause them to dissolve, meaning that given sufficient common ion concentrations erosion will not proceed, even if the pH is low. Interestingly, the addition of calcium is more effective than phosphate at reducing erosion in acid solutions. Today, several calcium-enriched soft drinks are on the market, and acidic products with high concentrations of calcium and phosphorus are available (such as yoghurt), which do not soften the dental hard tissues. The greater the buffering capacity of the drink or food, the longer it will take for the saliva to neutralize the acid. A higher buffer capacity of a drink or foodstuff will enhance the processes of dissolution because more release of ions from the tooth mineral is required to render the acid inactive for further demineralization. Temperature is also a significant physical factor; for a given acidic solution, erosion proceeds more rapidly the higher the temperature of that solution. In recent years, a number of interesting potentially erosion-reducing drink and food additives have been investigated.

The histological features and physical properties of eroded dental hard tissues.

Erosive demineralisation causes characteristic histological features. In enamel, mineral is dissolved from the surface, resulting in a roughened structure similar to an etching pattern. If the acid impact continues, the initial surface mineral loss turns into bulk tissue loss and with time a visible defect can develop. The microhardness of the remaining surface is reduced, increasing the susceptibility to physical wear. The histology of eroded dentine is much more complex because the mineral component of the tissue is dissolved by acids whereas the organic part is remaining. At least in experimental erosion, a distinct zone of demineralised organic material develops, the thickness of which depends on the acid impact. This structure is of importance for many aspects, e.g. the progression rate or the interaction with active agents and physical impacts, and needs to be considered when quantifying mineral loss. The histology of experimental erosion is increasingly well understood, but there is lack of knowledge about the histology of in vivo lesions. For enamel erosion, it is reasonable to assume that the principal features may be similar, but the fate of the demineralised dentine matrix in the oral cavity is unclear. As dentine lesions normally appear hard clinically, it can be assumed that it is degraded by the variety of enzymes present in the oral cavity. Erosive tooth wear may lead to the formation of reactionary or reparative dentine.

Prevalence, incidence and distribution of erosion.

There is evidence that the presence of erosion is growing steadily. Due to different scoring systems, samples and examiners, it is difficult to compare the different studies. Preschool children from 2 to 5 years showed erosion on deciduous teeth in 1 to 79% of the subjects. Schoolchildren (aged from 5 to 9 years) already had erosive lesions on permanent teeth in 14% of the cases. In the adolescent group (aged between 9 and 20 years), 7 to 100% of the persons examined showed signs of erosion. Incidence data (the increase in the number of subjects presenting signs of dental erosion) was evaluated in four of these studies and presented average annual values between 3.5 and 18%, depending on the initial age of the examined sample. In adults (aged from 18 to 88 years) prevalence data ranged between 4 and 100%. Incidence data are scarce in this age group, and only one study was found analysing the increase of affected surfaces, showing an incidence of 5% for the younger and 18% for older age groups. In general, males present more erosive tooth wear than females. The distribution showed a predominance of affected occlusal surfaces (mandibular first molars) followed by facial surfaces (anterior maxillary teeth). Oral erosion was frequently found on maxillary incisors and canines. Overall, prevalence data are not homogeneous. Nevertheless, there is a trend towards a more pronounced rate of erosion in younger age groups. Furthermore, a tendency was found for more erosive lesions with increasing age and these erosions progressed with age.

The future of fluorides and other protective agents in erosion prevention

The effectiveness of fluoride in caries prevention has been convincingly proven. In recent years, researchers have investigated the preventive effects of different fluoride formulations on erosive tooth wear with positive results, but their action on caries and erosion prevention must be based on different requirements, because there is no sheltered area in the erosive process as there is in the subsurface carious lesions. Thus, any protective mechanism from fluoride concerning erosion is limited to the surface or the near surface layer of enamel. However, reports on other protective agents show superior preventive results. The mechanism of action of tin-containing products is related to tin deposition onto the tooth surface, as well as the incorporation of tin into the near-surface layer of enamel. These tin-rich deposits are less susceptible to dissolution and may result in enhanced protection of the underlying tooth. Titanium tetrafluoride forms a protective layer on the tooth surface. It is believed that this layer is made up of hydrated hydrogen titanium phosphate. Products containing phosphates and/or proteins may adsorb either to the pellicle, rendering it more protective against demineralization, or directly to the dental hard tissue, probably competing with H(+) at specific sites on the tooth surface. Other substances may further enhance precipitation of calcium phosphates on the enamel surface, protecting it from additional acid impacts. Hence, the future of fluoride alone in erosion prevention looks grim, but the combination of fluoride with protective agents, such as polyvalent metal ions and some polymers, has much brighter prospects.

Susceptibility of enamel to initial erosion in relation to tooth type, tooth surface and enamel depth

This study aimed at assessing the susceptibility of different tooth types (molar/premolar), surfaces (buccal/lingual) and enamel depths (100, 200, 400 and 600 μm) to initial erosion measured by surface microhardness loss (ΔSMH) and calcium (Ca) release. Twenty molars and 20 premolars were divided into experimental and control groups, cut into lingual/ buccal halves, and ground/polished, removing 100 μm of enamel. The initial surface microhardness (SMH 0 ) was measured on all halves. The experimental group was subjected to 3 consecutive erosive challenges (30 ml/tooth of 1% citric acid, pH 3.6, 25 ° C, 1 min). After each challenge, ΔSMH and Ca release were measured. The same teeth were consecutively ground to 200, 400 and 600 μm depths, and the experimental group underwent 3 erosive challenges at each depth. No difference was found in SMH 0 between experimental and control groups. Multivariate nonparametric ANOVA showed no significant differences between lingual and buccal surfaces in ΔSMH (p = 0.801) or Ca release (p = 0.370). ΔSMH was significantly greater in premolars than in molars (p < 0.05), but not different with respect to enamel depth. Ca release decreased significantly with increasing depth. Regression between Ca release and ΔSMH at 100 μm depth showed lower slope and r 2 value, associated with greater Ca release values. At 200-600 μm depths, moderately large r 2 values were observed (0.651-0.830). In conclusion, different teeth and enamel depths have different susceptibility to erosion, so when Ca release is used to measure erosion, the depth of the test facet in enamel should be standardized, whereas this is less important if ΔSMH is used.