35

Dental erosion
SUMMARY
Tom is 9 years old. He is a new patient to your prac-
tice. On examination you are concerned by the
appearance of the occlusal surfaces of his lower
primary molars. What has caused this and how may
it be managed?
What do you see ( Fig. 35.1 )?
There is erosion of the cusps of Tom s primary molars
giving cupping or perimolysis of the cusps with loss of
enamel and visible underlying dentine.
How would you defne erosion?
An irreversible loss of tooth substance brought about by a
chemical process that does not involve bacterial action.
What foods and drinks have erosive potential?
See Box 35.1 . While a wide range of food and drinks is
implicated in the problem, the bulk of the damage is done
by soft drinks, especially carbonated drinks, which are
increasingly available from vending machines in schools
and recreational facilities. All carbonated drinks and fruit-
based drinks have lowered pH values but the direct rela-
tionship between pH and erosion is unclear. Other factors
such as titratable acidity, the inuence of plaque pH and the
Fig. 35.1 Erosion of cusp tips of primary molars.
Box 35.1 Foods and drinks with erosive potential
Citrus fruits, e.g. lemons, oranges, grapefruits.
Tart apples.
Vinegar and pickles.
Yoghurt.
All fruit juices including fresh juice and fruit-based squashes.
Carbonated drinks, including low-calorie varieties, sports drinks and sparkling
mineral water.
Vitamin C tablets.
Citrus fruits, e.g. lemons, oranges, grapefruits.
Tart apples.
Vinegar and pickles.
Yoghurt.
All fruit juices including fresh juice and fruit-based squashes.
Carbonated drinks, including low-calorie varieties, sports drinks and sparkling
mineral water.
Vitamin C tablets.
buffering capacity of saliva will all inuence the erosive
potential of a substrate. Three things, however, are clear
with erosive loss:
It is worse if consumption is high.
It is worse if consumption occurs at bedtime.
It is worse if brushing occurs directly after consumption.
Box 35.2 Conditions associated with chronic regurgitation in
children
Gastro-oesophageal refux.
Oesophageal stricture.
Chronic respiratory disease, e.g. asthma.
Disease of the liver/pancreas/biliary tree.
Overfeeding.
Feeding problems/failure to thrive conditions.
Mental handicap.
Cerebral palsy.
Rumination.
Gastro-oesophageal refux.
Oesophageal stricture.
Chronic respiratory disease, e.g. asthma.
Disease of the liver/pancreas/biliary tree.
Overfeeding.
Feeding problems/failure to thrive conditions.
Mental handicap.
Cerebral palsy.
Rumination.
History
Tom s only complaint was occasional sensitivity on his back
teeth as a result of the visible dentine.
What is the best way to fnd out about Tom s diet?
A 3- or 4-day written dietary history is the only way to
accurately elucidate a constituent of the diet that may be
erosive.
Can the pattern of erosion caused by dietary constituents
be related to the manner in which the substrate is
consumed?
This is indeed the case. Frothing of a drink between the
upper anterior teeth with its retention labially can lead to
palatal, interproximal and labial erosion. Retention of a
drink specically on one side of the mouth can lead to
erosion on that side only.
You have covered Tom s dietary history. Is your history now
complete or are there other questions you need to ask with
relation to erosion?
It is very important to consider gastric acid as a cause of
erosion, even in a younger patient. The conditions in chil-
dren that are associated with chronic regurgitation are
shown in Box 35.2 . The acidity of the stomach contents is
below pH 1.0 and therefore any regurgitation or vomiting
is damaging to the teeth.
35 D E N T A L E R O S I O N

144
What question would you ask to give you an indication that
regurgitation was occurring?
Do you ever have a bitter taste in your mouth? There is
a group of patients who have gastro-oesophageal reux
disease (GORD). This may be either symptomatic, in which
the individual knows what provokes the reux, or more
insidiously, asymptomatic GORD, where the patient is
unaware of the problem. The latter case is most likely to
occur at night when the horizontal sleeping position makes
it more likely that acid will reux through the lower
oesophageal sphincter. In this case the question about a
bitter taste in the mouth should have the sufx when you
wake up.
What is the common pattern of erosive loss when there is
chronic gastric regurgitation?
Initially there is erosion of the palatal surfaces of the upper
incisors, canines and premolars. With time this extends to
the occlusal and buccal surfaces of the lower molars and
premolars.
Whenever there is unexplained erosive loss, an eating
disorder should be suspected. There are three such disor-
ders: anorexia nervosa; bulimia nervosa; and rumination.
The latter is a condition in which food is voluntarily regur-
gitated into the oral cavity and either expelled or swallowed
again.
Is there a specifc pattern of erosive loss in recurrent
vomiting?
All tooth surfaces can be affected with the relative exception
of the lingual surfaces of the lower teeth, which are pro-
tected by the tongue and the saliva from the sublingual
papillae.
What would you do if you suspect after questioning Tom
and his parents that there may be asymptomatic GORD?
Referral to a paediatrician with an interest in gastrointesti-
nal disease would be appropriate. The paediatrician will
seek to eliminate organic disease and then attempt to quan-
tify the problem. The latter may involve 24-hour pH moni-
toring of the oesophagus with probes in the lower and
upper oesophagus. An additional probe could be added to
an intraoral appliance to measure mouth pH. Medical and/
or surgical treatment may be required to control GORD.
Chronic regurgitation can lead to scarring of the oesopha-
gus and dysplastic change, and this is therefore an impor-
tant condition to diagnose and treat.
Summary of Toms history
There was no evidence of any gastrointestinal illness but
Tom did consume a number of zzy drinks, especially
between meals and when he was at the local sports centre.
In addition to these he also drank water and milk.
What advice would you give to Tom regarding his high
intake of fzzy drinks?
It is critically important when dealing with children and
adolescents not to be too dogmatic in your advice and it
is unrealistic to expect youngsters who have been brought
up with a high intake of carbonated beverages to stop
altogether.
They should be advised to eradicate between-meal zzy drink
consumption but to have the zzy drink with meals and
preferably to drink it with a straw. The presence of food, and
the extra saliva that is generated at mealtimes, will help to
neutralize the acidity. In addition, a straw will deposit the
majority of the carbonated beverage beyond the teeth.
Make sure that the between-meal carbonated drink is not
substituted by something with a similar erosive potential, e.g.
fresh fruit juice or a juice-based squash.
Milk and water are the most appropriate between-meal
drinks. If either of these proves impossible then an extremely
well diluted no added sugar squash can be accepted.
No carbonated drinks or fruit drinks should be given last
thing at night.
Advocate the consumption of a neutral food immediately
after a meal, e.g. cheese.
Management
The most important aspect of the management of Toms
erosion was early diagnosis before there had been damage
to the permanent teeth, and subsequently to establish the
aetiology and eliminate the cause.
Key point
Management of erosion:
Early diagnosis.
Establish aetiology.
Eliminate cause.
Tom only has occasional sensitivity. What treatment, if any,
does he need?
Probably none. The following would be realistic initially:
Daily neutral sodium uoride mouthwash to try to give
maximum resistance to remaining enamel and desensitize the
dentine.
High concentration sodium uoride varnish (Duraphat) to be
applied three times a year.
If there is progressive sensitivity then the areas of enamel
loss and dentine exposure could be protected by an adhe-
sive restoration. In many cases if erosion is diagnosed early
then preventive counselling and the above advice may be
sufcient. It is a good idea to make study casts of all patients
with signs of erosion or attrition or abrasion to monitor the
rate of progression. In more advanced cases than Tom, as
in Figure 35.2A, B where there is signicant sensitivity or
Fig. 35.2 (A) Signicant erosive tooth surface loss of labial surfaces
of upper permanent incisors.
35 D E N T A L E R O S I O N
145

Erosion is only one element of tooth surface loss or wear.

What are the other elements?
Attrition: the wear of the tooth as a result of tooth-to-tooth
contact.
Abrasion: physical wear of tooth substance produced by
something other than tooth-to-tooth contact.
In children, abrasion is usually due to overzealous tooth-
brushing, which tends to develop with increasing age. The
abnormal brushing technique must be corrected before sig-
nicant tooth tissue is removed and pulpal exposure occurs.
Attrition caused by normal mastication is common espe-
cially with the ageing primary dentition. Almost all primary
teeth show signs of attrition by the time they exfoliate.
What categories of patient exhibit more attrition than
normal?
Those with signicant parafunctional activity, e.g. cerebral
palsy and other physical and developmental disorders with
intracranial abnormalities. Controlling attritional wear in
these patients can be very difcult. Some drugs act to try to
reduce such parafunctional activity but even if this is suc-
cessful in the limbs there is often still residual oral parafunc-
tion. This is probably due to the neuronal sensitivity of the
mouth and the structures within it.
What restorative materials are the most durable for
attritional wear as a result of parafunction?
Amalgam and stainless steel crowns.
Recommended reading
Kilpatrick NM, Welbury RR 2005 Advanced restorative
dentistry. In: Welbury RR, Duggal MS, Hosey MT (eds)
Paediatric Dentistry, 3rd edn. Oxford University Press,
Oxford, pp 205230.
Shaw L, OSullivan E 2000 UK National Clinical
Guidelines in Paediatric Dentistry. Diagnosis and
prevention of dental erosion in children. Int J Paediatr
Dent 10:356365.
For revision, see Mind Map 35, page 197.
Table 35.1 Treatment techniques for tooth surface loss
Technique Advantages Disadvantages
Cast metal
(nickel/chrome or
gold)
Fabricated in thin section
requires only 0.5 mm
space
May be cosmetically unacceptable
due to shine through of metallic
grey
Very accurate t possible Cannot be simply repaired or
added to intraorally
Very durable
Suitable for posterior
restorations in
parafunction
Does not abrade opposing
dentition
Composite: direct Least expensive Technically dicult for palatal
veneers
Can be added to and
repaired intraorally
Limited control over occlusal and
interproximal contour
Aesthetically superior to
cast metal
Inadequate as a posterior
restoration
Composite:
indirect
Can be added to and
repaired intraorally
Requires more space minimum
of 1.0 mm
Aesthetically superior to
cast metal
Unproven durability
Control over occlusal
contour and vertical
dimension
Porcelain Best aesthetics Potentially abrasive to opposing
dentition
Good abrasion resistance Inferior marginal t
Well-tolerated by gingival
tissues
Very brittle has to be used in
bulk section
Hard to repair
Key point
Treatment objectives for erosion:
Resolve sensitivity.
Restore missing tooth surface.
Prevent further tooth tissue loss.
Maintain a balanced occlusion.
cosmetic problems, then more active intervention is
required. Table 35.1 shows the merits of the different
options available.
Fig. 35.2 (B) Signicant erosive tooth surface loss of palatal
surfaces of upper permanent incisors.
41
197

MI N D MA P 3 5
citrus fruits
tart apples
vinegar and pickles
yoghurt foods and drinks
leisure
medications and oral hygiene products
swimming pools
fruit juices
carbonated drinks
vitamin C tablets
gastro-oesophageal reflux
oesophageal stricture
chronic respiratory disease
liver / pancreas / biliary disease
overfeeding
failure to thrive
mental handicap
cerebral palsy
rumination
anorexia / bulimia
drug induced
gastric acid
intrinsic
extrinsic
Aetiology
Medical treatment and investigation
cast metal onlays
composite
porcelain
direct
indirect
Restorative treatment
high fluoride paste
low abrasive paste
fluoride varnish
fluoride supplements
sugar-free gum
bonding agents
Desensitization
limit acids to meals
reduce frequency
finish meal with alkaline foods
avoid acid foods at night
avoid toothbrushing after acid foods
check pH of medications / mouthwashes
Dietary advice
diet diary
study models
photographs
diagnostic index
Dental investigation
drugs for reflux
bulimia / anorexia
surgery
oesophageal monitoring
Dental Erosion