Tooth Wear/Dental Erosion

Some of our patients present with tooth wear; much of it caused by dental erosion (the dissolution of teeth by acids), the best service that we can provide for our patients with tooth wear / erosion is to identify it early. Once identified the next step is to attempt to determine the cause and recommend preventive measures. Early identification is crucial as tooth wear is a lifetime cumulative process.
It is essential however to remember that dental caries is still the most common childhood disease and also one of the most preventable diseases.

Aetiology

The frequent consumption of acidic drinks, such as carbonated drinks and drinks marketed as pure fruit juices and fruit squashes are commonly implicated. Not only the quantity but the frequency and the manner with which acidic drinks and foods are consumed are important in the aetiology. Habits such as holding the drink in the mouth for a long time, swishing the drink around or swilling the drink can be damaging to the teeth.
Protracted sucking on citrus fruits or grapes can also be a cause.
Erosion may be associated with gastric upset, vomiting, anorexia nervosa and bulimia nervosa. This should be borne in mind when speaking to a patient so that there is sufficient empathy, sensitivity and confidentiality.
It is helpful to keep in mind that it is not only what the patient is consuming, but when they consume it and how they consume it.

What? When? How?
The cause may not be immediately evident and recording dietary intake over four consecutive days may be helpful, it should include one day at the weekend, the time of day and quantity of all ingested foods and beverages and any dietary or vitamin supplements should be recorded.
Some tooth wear / erosion may be historic and it is worth querying whether there was a change in dietary practices, habits or general health.

Appearance

Look for signs of tooth wear / erosion as part of the clinical examination; note it in the patient’s record if present. Lesions do not need to be routinely restored but the opportunity to identify the cause is necessary.

What to look for
Children attending with upper primary incisors present may have considerable loss of palatal enamel, which may indicate dietary habits, leading to erosion. Despite extensive loss it is typical to have an intact border of enamel along the palatal or labial gingival margin (rimming). It almost resembles a preparation for a Veneer

At the mixed dentition stage the opportunity to examine the primary canines and the first and second primary molars is available

At this time the first permanent molars should also be examined.

The term ‘cupping’ is used to describe occlusal and incisal surfaces where the enamel has dissolved from the surface leaving discrete pits or a washed out appearance. Areas where the surface anatomy is no longer visible may also occur.

In the permanent upper incisors changes to the labial contour, may occur so that the surface appears smooth and shiny with loss of surface characteristics

which may then be followed by flattening of the surface and then the appearance of concavities in the enamel. Incisal surfaces also demonstrate changes with chipping

or flattening of the incisal edges being evident.

Changes to the palatal surface also occur so that the surface characteristics are now longer present and the surface appears smooth, with possibly evidence of ‘rimming’

Management

At the early stages greatest emphasis is placed on prevention.

Acidic foods and drinks should be confined to meal times and swallowed rather than held in the mouth for any duration of time.

Consideration should be given to the individual’s normal oral hygiene routine so that a fluoride tooth paste is recommended twice daily

Attention to the way the teeth are brushed is also required so that additional tooth surface is not abraded.

Check that the teeth are not being brushed immediately after acidic foods and drinks.

Not all tooth wear requires restorations, but the institution of early preventive measures is critical.

The above information is to assist with recognising tooth wear / erosion early and managing it principally with prevention. The information has not dealt with the management of the severe cases, which often require extensive and specialist restoration.
There are many excellent texts available providing comprehensive information on tooth wear.