Erosion. Causes, manifestations in oral cavity, diagnosis making and its therapy

 Dental erosion is defined as irreversible loss of dental hard tissue by a chemical process that does not involve bacteria.  Dissolution of mineralized tooth structure occurs upon contact with acids that are introduced into the oral cavity from -intrinsic (e.g., gastroesophageal reflux, vomiting) - extrinsic sources (e.g., acidic beverages, citrus fruits).

Behaviour  Acid erosion often coexists with abrasion and attrition. Abrasion is most often caused by brushing teeth too hard.  Throthing or swishing acidic drinks around the mouth increases the risk of acid erosion

Frequently consumed foods and drinks  Dental erosion is the most common chronic disease of children ages 5–17.  Frequently consumed foods and drinks below pH 5.0–5.7 may intitiate dental erosion.

Main causes of tooth surface loss  Attrition  Abrasion  Abfraction  Corrosion (Erosion)

Attrition  This is natural tooth-to-tooth friction that happens when you clench or grind your teeth such as with bruxism, which often occurs involuntary during sleep.

Abrasion  This is physical wear and tear of the tooth surface that happens with brushing teeth too hard, improper flossing, biting on hard objects (such as fingernails, bottle caps, or pens), or chewing tobacco.

Abfraction.  This occurs from stress fractures in the tooth such as cracks from flexing or bending of the tooth.

Corrosion (Erosion)  This occurs chemically when acidic content hits the tooth surface such as with certain medications like aspirin or vitamin C tablets, highly acidic foods, GERD, and frequent vomiting from bulimia or alcoholism.

Extrinsic causes  Acidic beverages, foods  Carbonated drinks, sport drinks  Medications-chewed and held prior swallowing e.g C vit preparations  calcium, phosphates, fluoride may lessen erosive potential  Proximity of toothbrushing after intake  Work environment. Swimmers, winetasters

Intrinsic causes  Gastric acids regurgitated into the esophagus and mouth. Gastric acids, with pH levels that can be less than 1, reach the oral cavity and come in contact with the teeth GERD  Excessive vomiting related to eating disorders.(anorexia, bulimia, alcoholism, pregnancy, drug side effect, diabetes..)

Signs  changes in appearance and sensitivity  the cutting edge of the tooth to become transparent  the tooth has a yellowish tint  change in shape of the teeth  a broad rounded concavity, and the gaps between teeth will become larger  the teeth may form divots on the chewing surfaces  include pain when eating hot, cold, or sweet foods

Grade description  0 No visible erosion  1 Small pits and slightly rounded cusps, flattened fissures, moderate cupping, preservation of occlusal surface morphology  2 Depression of cusps with severe cupping and grooving, restoration margins raised above level of surrounding tooth, flattening of occlusal surface morphology

Grade description  0 No erosion  1 Loss of surface detail; change confined to enamel  2 Exposure of dentin affecting less than one-third of crown  3 Exposure of dentin affecting one-third or more of crown

Making a diagnosis  These definitions relate to different causes, it is important to recognize that each of these types of tooth wear rarely occur alone in a given individual. A patient with generalized tooth wear may be diagnosed as being a bruxer or a heavy- handed toothbrusher, without recognition of an erosive component to the problem and clinical research in the area of tooth wear difficult.  Likewise, the diagnosis and management of patients with tooth erosion remains a challenging task.

 Many studies suggest that the incidence of dental erosion ranges from 5 to 50% in various populations and age groups.

Treatment

Saliva  Saliva acts as a buffer, regulating the pH when acidic drinks are ingested  Fruit juices are the most resistant to saliva's buffering effect  Followed by, in order: -fruit-based carbonated drinks -flavoured mineral waters -non-fruit-based carbonated drinks, sparkling mineral waters

Saliva as a Modifying factor  Buffering capacity due to the bicarbonate content of the saliva which is in turn dependent on salivary flow rate.  many common medications and diseases can lower salivary flow rate when evaluating a patient with erosion.

Treatment  Head elevation (extra pillows during sleep)  Dietary modification (avoiding spicy or fatty foods)  Use of antacids

Anorexia, bulimia  erosion caused by vomiting typically affects the palatal surfaces of the maxillary teeth  treatment for bulimia may include use of antidepressants or other psychoactive medications these may cause salivary hypofunction

 Sjogren’s syndrome is an autoimmune condition in which chronic inflammation of the salivary and tear glands cause dry mouth and eyes  a patient may use acidic beverages in efforts to stimulate residual salivary flow and keep the mouth moist

 Brushing immediately after the consumption of acidic foods, or vomiting may also accelerate tooth structure loss because the enamel is softened by the presence of acid

 the teeth may appear more yellow as the underlying dentin shows through  A patient may attempt to whiten the teeth by more rigorous brushing with a toothpaste that is more abrasive (e.g., toothpaste advertised to smokers), compounding the erosion with abrasion. Fluoride use should be assessed.

 Caries is generally an uncommon occurrence in patients with erosion. Additionally, teeth with erosion do not tend to retain plaque.

 The location, degree and type of tooth surface loss should be documented by careful description.  Radiographs, impression…

Prevention and treatment  Identification of the etiology  Treating the underlying medical disorder or disease.  Symptoms of GERD,then he/she should be referred to a medical doctor  With salivary hypofunction may benefit with the use of sugarless chewing gum or mints to increase residual salivary flow.  The use of oral pilocarpine (Salagen) may be beneficial in patients with dry mouth

Prevention and treatment  Decrease abrasive forces.  Use a soft bristled toothbrush and brush gently  No brushing immediately after consuming acidic food and drink as teeth will be softened. Leave at least half an hour of time space. Rinsing with water is better than brushing after consuming acidic foods and drinks  Drinking through a straw

Prevention and treatment  A patient suspected of an eating disorder should be referred to a medical doctor for evaluation.  Dietary modification  Using a remineralizing agent, such as sodium fluoride solution in the form of a fluoride mouthrinse, tablet, or lozenge, immediately before brushing teeth  Applying fluoride gels or varnishes to the teeth  Drinking milk or using other dairy products  Using a neutralizing agent such as antacid tablets  Dentine bonding agents applied to areas of exposed dentin

Prevention and treatment Restorative treatment can range from placement of bonded composites in a few isolated areas of erosion, to full mouth reconstruction in the case of the devastated dentition. Restorative treatment can range from placement of bonded composites in a few isolated areas of erosion, to full mouth reconstruction in the case of the devastated dentition.