DENTAL EROSION—TOOTH WEAR

DENTAL EROSION—TOOTH WEAR
Physiology, Etiology, Epidemiology, Diagnosis, and Treatment Reviewed by:

Dental Erosion: Tooth Wear
After viewing this lecture, attendees should be able to: understand the oral anatomy and physiology as they relate to dental erosion/tooth wear identify the etiology of and risk factors associated with dental erosion/tooth wear describe the epidemiology and prevalence of dental erosion/tooth wear make the correct differential diagnosis and understand the management of dental erosion/tooth wear

Oral Anatomy and Physiology
Definition (teeth): There are two definitions Primary (deciduous) Secondary (permanent) There are two general categorizations for teeth: Primary (deciduous) teeth Secondary (permanent) teeth

Dentition (teeth): There are two dentitions Primary (deciduous) Consist of 20 teeth Begin to form during the first trimester of pregnancy Typically begin erupting around 6 months Most children have a complete primary dentition by 3 years of age Primary (deciduous) Consist of 20 teeth Begin to form during the first trimester of pregnancy Typically begin erupting around 6 months Most children have a complete primary dentition by 3 years of age 1. Oral Health for Children: Patient Education Insert. Compend Cont Educ Dent.

Dentition (teeth): There are two dentitions Incisors Canine (Cuspid) Premolars Molars Maxilla Secondary (permanent) Consist of 32 teeth in most cases Begin to erupt around 6 years of age Most permanent teeth have erupted by age 12 Third molars (wisdom teeth) are the exception; often do not appear until late teens or early 20s Secondary (permanent) Consist of 32 teeth in most cases Begin to erupt around 6 years of age Most permanent teeth have erupted by age 12 Third molars (wisdom teeth) are the exception; often do not appear until late teens or early 20s Mandible

Identifying Teeth Classification of Teeth: Incisors (central and lateral) Canines (cuspids) Premolars (bicuspids) Molars Teeth may be classified based on structure/function: Incisors (central and lateral) Canines (cuspids) Premolars (bicuspids) Molars Incisor Canine Premolar Molar

Labial Apical Lingual Distal Apical Mesial Teeth: Identification Tooth Surfaces Apical Labial Lingual Distal Mesial Incisal Tooth surfaces include: Apical: Pertaining to the apex or root of the tooth Labial: Pertaining to the lip; describes the front surface of anterior teeth Lingual: Pertaining to the tongue; describes the back (interior) surface of all teeth Distal: The surface of the tooth that is away from the median line Mesial: The surface of the tooth that is towards the median line Incisal

Anatomic Crown The 3 parts of a tooth: Anatomic Crown Anatomic Root Pulp Chamber Pulp Chamber The anatomic tooth crown is the portion of the tooth covered by enamel. The anatomic root is the lower two thirds of a tooth. The roots are normally subgingival, buried in bone, and serve to anchor the tooth in position. The pulp cavity houses the dental pulp, an organ of myelinated and unmyelinated nerves, arteries, veins, lymph channels, connective tissue cells, and various other cells involved in formative or developmental, nutritive, sensory, protective, and defensive or reparative processes. Anatomic Root

Enamel The 4 main dental tissues: Dental Pulp Dentin Enamel Dentin Cementum Dental Pulp The 4 main dental tissues are: Enamel Dentin Cementum Dental pulp Cementum

Dental Tissues—Enamel2 Structure Highly calcified and hardest tissue in the body Crystalline in nature Enamel rods Insensitive—no nerves Acid-soluble—will demineralize at a pH of 5.5 and lower Cannot be renewed Darkens with age as enamel is lost Fluoride and saliva can help with remineralization Structure Highly calcified and hardest tissue in the body Crystalline in nature Enamel rods Insensitive—no nerves Acid-soluble—will demineralize at a pH of 5.5 and lower Cannot be renewed Darkens with age as enamel is lost Fluoride and saliva can help with remineralization

Dental Tissues—Dentin2 Softer than enamel Susceptible to tooth wear (physical or chemical) Does not have a nerve supply but can be sensitive Is produced throughout life Three classifications Primary Secondary Tertiary Will demineralize at a pH of 6.5 and lower Softer than enamel Susceptible to tooth wear (physical or chemical) Does not have a nerve supply but can be sensitive Is produced throughout life Three classifications Primary Secondary Tertiary Will demineralize at a pH of 6.5 and lower Primary dentin forms the initial shape of the tooth. It is usually completed 3 years after tooth eruption (for permanent teeth). Secondary dentin is deposited after the formation of the primary dentin. Secondary dentin forms on all internal aspects of the pulp cavity, but in the pulp chamber of multirooted teeth it tends to be thicker on the roof and floor than on the side walls. Tertiary dentin, or “reparative dentin” is formed by replacement odontoblasts in response to moderate-level irritants such as attrition, abrasion, erosion, trauma, moderate-rate dental caries, and some operative procedures. It usually appears as a localized dentin deposit on the wall of the pulp cavity immediately subadjacent to the area of the tooth that has received the injury.

Dentin Dental Tissues—Dentin (Tubules)2 Pulp Presence of tubules renders dentin permeable to fluoride Number of tubules per unit area varies depending on the location because of the decreasing area of the dentin surfaces in the pulpal direction Tubule Odontoblast Cell Nerve Fibers The tubules run parallel to each other in an S-shape course. The tubules are filled with a fluid. External stimuli cause movement of the dentinal fluid, a hydrodynamic movement, which can result in short, sharp pain episodes. These details are important in understanding dentin hypersensitivity. Fluid

Enamel Dental Tissues—Dentin (Tubules)2 Association between erosion and dentin hypersensitivity3 Open/patent tubules – Greater in number – Larger in diameter Removal of smear layer Erosion/tooth wear Tubules Exposed Dentin Odontoblast Associations between erosion and hypersensitivity involve: Open/patent tubules Greater in number Larger in diameter Removal of smear layer Erosion/tooth wear Undercalcified Receding Gingiva

Dental Tissue—Cementum2 Thin layer of mineralized tissue covering the dentin Softer than enamel and dentin Anchors the tooth to the alveolar bone along with the periodontal ligament Not sensitive Cementum is: Thin layer of mineralized tissue covering the dentin Softer than enamel and dentin Anchors the tooth to the alveolar bone along with the periodontal ligament Not sensitive

Dental Tissue—Dental Pulp2 Innermost part of the tooth A soft tissue rich with blood vessels and nerves Responsible for nourishing the tooth The pulp in the crown of the tooth is known as the pulp chamber Pulp canals traverse the root of the tooth Typically sensitive to extreme thermal stimulation (hot or cold) Dental pulp is: Innermost part of the tooth A soft tissue rich with blood vessels and nerves Responsible for nourishing the tooth The pulp in the crown of the tooth is known as the pulp chamber Pulp canals traverse the root of the tooth Typically sensitive

Oral Cavity/Environment4,5 Plaque Saliva pH Values Demineralization Remineralization The oral environment consists of: Plaque Saliva pH Values Demineralization Remineralization

Oral Cavity Plaque:4,5 is a biofilm contains more than 600 different identified species of bacteria there is harmless and harmful plaque salivary pellicle allows the bacteria to adhere to the tooth surface, which begins the formation of plaque Plaque:4,5 is a biofilm contains more than 400 different identified species of bacteria there is harmless and harmful plaque salivary pellicle allows the bacteria to adhere to the tooth surface, which begins the formation of plaque

Oral Cavity Saliva:4,5 complex mixture of fluids performs protective functions: lubrication—aids swallowing mastication key role in remineralization of enamel and dentin buffering Saliva:4,5 complex mixture of fluids performs protective functions: lubrication—aids swallowing mastication key role in remineralization of enamel and dentin buffering

Oral Cavity pH values:4,5 measure of acidity or alkalinity of a solution measured on a scale of 1-14 pH of 7 indicated that the solution is neutral pH of the mouth is close to neutral until other factors are introduced pH is a factor in demineralization and remineralization pH values:4,5 measure of acidity or alkalinity of a solution measured on a scale of 1-14 pH of 7 indicates that the solution is neutral pH of the mouth is close to neutral until other factors are introduced pH is a factor in demineralization and remineralization 3. Strassler HE, Drisko CL, Alexander DC.

Oral Cavity Demineralization:4,5 mineral salts dissolve into the surrounding salivary fluid: enamel at approximate pH of 5.5 or lower dentin at approximate pH of 6.5 or lower erosion or caries can occur Demineralization:4,5 mineral salts dissolve into the surrounding salivary fluid: enamel at approximate pH of 5.5 or lower dentin at approximate pH of 6.5 or lower erosion or caries can occur

Oral Cavity Remineralization:4,5 pH comes back to neutral (7) saliva-rich calcium and phosphates minerals penetrate the damaged enamel surface and repair it: enamel pH is above 5.5 dentin pH is above 6.5 Remineralization:4,5 pH comes back to neutral (7) saliva-rich calcium and phosphates minerals penetrate the damaged enamel surface and repair it: enamel pH is above 5.5 dentin pH is above 6.5

Dental Erosion: Etiology
Tooth Wear Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of physical loss, chemical dissolution, and/or multifactorial etiology.3,6 Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of physical loss, chemical dissolution, and/or multifactorial etiology.3,6

Tooth Wear Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of:3,6 Physical Loss – Abrasion—mechanical – Attrition—tooth-to-tooth contact – Abfraction—lesions Chemical dissolution Multifactorial etiology Abrasion is usually caused be excessive tooth brushing with highly abrasive toothpastes and/or aggressive oral hygiene habits (hard bristles with much manual force, reloading the brush with paste, etc).3 Attrition is wear resulting from tooth-to-tooth contact such as occlusal parafunctional habits, or in the regular function of mastication of abrasive foods. 3 Abfraction is a non-carious cervical lesion hypothetically caused by occlusal parafunctional forces. Loss of enamel resulting from trauma can lead to exposed dentin. Abfraction also puts the tooth at risk of dentin/root surface chemical erosion. 3

Tooth Wear Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of:3,6 Physical Loss Chemical dissolution – Erosion -- Extrinsic acids -- Intrinsic acids Multifactorial etiology Chemical erosion of the enamel and dentin is most commonly produced by excessive and frequent intake of an acidic diet and less commonly by the reflux of hydrochloric acid from the stomach. Acids demineralize and soften the enamel and dentin surfaces, making them more susceptible to abrasion, particularly by toothbrushing with or without toothpaste.3 24

Tooth Wear Destruction of the dental tissues (enamel, dentin, cementum) can occur as a result of:3,6 Physical Loss Chemical dissolution Multifactorial etiology – Erosion – Abrasion – Attrition – Abfraction Multifactorial causes include the combination of erosion and abrasion, with erosion initiating wear and abrasion localizing it to a particular part of the tooth.3 25

Abrasion The pathological wearing away of hard dental tissue through abnormal mechanical processes involving foreign objects or substances repeatedly introduced in the mouth and contacting the teeth.6 Oral hygiene habits Excessive brushing/flossing Abrasives in dentifrices/toothpastes Personal habits Putting foreign objects in the mouth Demastication Wear from chewing food Abrasion is: The pathological wearing away of hard dental tissue through abnormal mechanical processes involving foreign objects or substances repeatedly introduced in the mouth and contacting the teeth.6 Oral hygiene habits Excessive brushing/flossing Abrasives in dentifrices/toothpastes Personal habits Putting foreign objects in the mouth Demastication Wear from chewing food

Attrition The pathological wearing away of hard dental tissue as a result of tooth-to-tooth contact, with no foreign substance intervening.6 Enamel wearing enamel Occlusal wear Malocclusion (buccal, lingual, and interproximal surfaces) Attrition is the pathological wearing away of hard dental tissue as a result of tooth-to-tooth contact, with no foreign substance intervening.6 Enamel wearing enamel Occlusal wear Malocclusion (buccal, lingual, and interproximal surfaces)

Abfraction Wedge-shaped defects at the cementoenamel junction of a tooth caused by eccentrically applied occlusal forces leading to tooth flexure that results in microfracture of enamel and dentin.6 Loss of tooth in the cervical area Tooth flexure – Chewing – Grinding (bruxism) Abfraction is wedge-shaped defects at the cementoenamel junction of a tooth caused by eccentrically applied occlusal forces leading to tooth flexure that results in microfracture of enamel and dentin.6 Loss of tooth in the cervical area Tooth flexure Chewing Grinding (bruxism)

The physical results of a pathologic, chronic, localized loss of hard dental tissue that is chemically etched away from the tooth surface by acid and/or chelation without bacterial involvement.7 Extrinsic acids—ingested Food, beverages, medicine Intrinsic acids—internal Originate in the stomach Erosion is the physical results of a pathologic, chronic, localized loss of hard dental tissue that is chemically etched away from the tooth surface by acid and/or chelation without bacterial involvement.7 Extrinsic acids—ingested Food, beverages, medicine Intrinsic acids—internal Originate in the stomach

Multifactorial Tooth wear is multifactorial One process typically impacts the other Erosion and abrasion Tooth wear is multifactorial One process typically impacts the other Erosion and abrasion

Dental Erosion: Epidemiology
Tooth erosion was described as a condition distinct from caries as early as the 18th century.8

Change in Perception In 1995, the European Journal of Oral Science stated that “dental erosion is an area of research and clinical practice that will undoubtedly experience expansion in the next decade.”9 In 1995, the European Journal of Oral Science stated that “dental erosion is an area of research and clinical practice that will undoubtedly experience expansion in the next decade.” This quote has proven correct as the number of published studies increase substantially: In the 1970s less than 5 studies per year were published about erosion, less than 10 in the 1980s, but has now increased to about 50 studies per year.17

Global Prevalence Global data on the prevalence of dental erosion is building. “Erosive tooth wear is a common condition in the developed countries.”10 United States Canada Iceland Ireland Sweden Germany Turkey Saudi Arabia India Brazil Japan Malaysia Switzerland The Netherlands UK China It is difficult to compare the results of epidemiological studies because of different examination standards. However, it is important to remember that while detection and prevalence of erosion may vary, it is something that affects all sectors of society and is independent of age. The emerging clinical studies tend to focus on schoolchildren and adolescents because they are much easier to recruit than adults. In the years to come, incidences will be apparent as these current study patients age.

Global Prevalence European studies suggest prevalence of:11-13 Up to 50% if all preschool children Between 24% to 60% of school-aged children As high as 82% in 18 to 88 years of age10 Emerging prevalence studies providing data on gender, socio-economic status, ethnic, and culture difference in addition to the age factor will prove to be invaluable European studies suggest prevalence of:11-13 Up to 50% of all preschool children Between 24% to 60% of school-aged children As high as 82% in 18 to 88 years of age10 Emerging prevalence studies providing data on gender, socio-economic status, ethnic, and culture difference in addition to the age factor will prove to be invaluable

Dental Erosion: Diagnosis
“Diagnosis is the intellectual course that integrates information obtained by clinical examination of the teeth, use of diagnostic aids, conversation with the patient, and biological knowledge. A proper diagnosis cannot be performed without inspection of the teeth and their immediate surroundings.”14 As Kidd et al noted in their contribution to Dental Caries: The Disease and its Clinical Management: “Diagnosis is the intellectual course that integrates information obtained by clinical examination of the teeth, use of diagnostic aids, conversation with the patient, and biological knowledge. A proper diagnosis cannot be performed without inspection the teeth and their immediate surroundings.”14

Dental Erosion—Diagnosis
Check list to unveil etiological factors for erosion15 Check list to unveil etiological factors for erosion15 Case history (medical and dental) Detection of the main noncarious hard tissue lesions (site-specific distribution) Record dietary intake over 4 days (estimation of the erosive potential) Specific factors that the patient may not be aware of: Diet Herbal teas, acidic candies, alcohol, sports drinks, effervescent vitamin C tablets, etc Gastric Symptoms Vomiting, acid taste in mouth, gastric pain (especially when awake), stomach ache, any sign of anorexia nervosa Drugs Alcohol, tranquillizers, antiemetics, antihistamines, lemonade tablets (change of acidic or saliva-reducing drugs is possible) Determination of flow rate and buffering capacity of saliva Oral hygiene habits (technique, abrasivity of toothpaste) Occupational exposure to acidic environments X-ray therapy of the head area Silicone impressions, study models, and/or photographs to assess further progression

Interaction of the different factors for the development of erosive tooth wear16,18 Different factors interact in the development of erosive tooth wear. These include: Biological factors such as saliva, soft tissue, tooth anatomy/structure, and the pellicle. Chemical factors such as pH, buffering capacity, acid types, adhesion, chelators, calcium phosphate, and fuoride. Behavioral factors such as eating and drinking habits, toothbrushing, acidic bottle feeding, regurgitation, vomiting, drugs, and occupation. From: Lussi A. Dental Erosion: From Diagnosis to Therapy. Karger; 2006.

Clinical Appearance There is no device available for the specific detection of dental erosion in routine practice. Therefore, the clinical appearance is the most important feature for dental professionals to diagnosis dental erosion.16 There is no device available for the specific detection of dental erosion in routine practice. Therefore, the clinical appearance is the most important feature for dental professionals to diagnosis dental erosion.16

Dental Erosion—Diagnosis
Tooth Wear—Clinical Appearance17 Abrasion is Usually located at cervical areas of teeth Lesions are more wide than deep Premolars and cuspids are more commonly affected Attrition is Matching wear on occluding surfaces Shiny facets on amalgam contacts Enamel and dentin wear at the same rate Possible fracture of cusps or restorations Abfraction Affects buccal/labial cervical areas of teeth Deep, narrow V-shaped notch Commonly affects single teeth with excursive interferences or eccentric occlusal loads Erosion is Broad concavities within smooth surface enamel Cupping of occlusal surfaces (incisal grooving) with dentin exposure Increased incisal translucency Wear on non-occluding surfaces "Raised" amalgam restorations Clean, non-tarnished appearance of amalgams Loss of surface characteristics of enamel in young children Preservation of enamel "cuff" in gingival crevice is common Dentin hypersensitivity Pulp exposure in deciduous teeth

Erosion is multifactorial Chemical factors—erosive potential of intrinsic and extrinsic acids Biological factors—involve properties and characteristics of the oral cavity Behavioral factors—personal and oral habits Erosion is multifactorial Chemical factors—erosive potential of intrinsic and extrinsic acids Biological factors—involve properties and characteristics of the oral cavity Behavioral factors—personal and oral habits

Chemical Factors18 pH and buffering capacity of the product Type of acid (pKa values) Intrinsic (gastric origin) Extrinsic (environmental, dietary, medicinal) Adhesion of the products to the dental surface Chelating properties of the products Calcium concentration Phosphate concentration Fluoride concentration Chemical Factors18 pH and buffering capacity of the product Type of acid (pKa values) Intrinsic (gastric origin) Extrinsic (environmental, dietary, medicinal) Adhesion of the products to the dental surface Chelating properties of the products Calcium concentration Phosphate concentration Fluoride concentration

Biological Factors19 Saliva: flow rate, composition, buffering, capacity, and stimulation capacity Acquired pellicle: diffusion-limiting properties, composition, maturation, and thickness Type of dental substrate (permanent and primary enamel, dentin) and composition (eg, fluoride content as FHAp or CaF2-like particles) Dental anatomy and occlusion Anatomy of oral soft tissues in relationship to the teeth Physiologic soft tissue movements Biological Factors19 Saliva: flow rate, composition, buffering capacity, and stimulation capacity Acquired pellicle: diffusion-limiting properties, composition, maturation, and thickness Type of dental substrate (permanent and primary enamel, dentin) and composition (eg, fluoride content as FHAp or CaF2-like particles) Dental anatomy and occlusion Anatomy of oral soft tissues in relationship to the teeth Physiological soft tissue movements

Behavioral Factors20 Unusual eating and drinking habits Healthy lifestyle: diets high in acidic fruits and vegetables Unhealthy lifestyle: frequent consumption of “alcopops” and designer drugs Alcoholic disease Excessive consumption of acidic foods and drinks Nighttime baby bottle feeding with acidic beverages, including milk Oral hygiene practices: frequent toothbrushing, abrasive oral care products Behavioral Factors20 Unusual eating and drinking habits Healthy lifestyle: diets high in acid fruits and vegetables Unhealthy lifestyle: frequent consumption of “alcopops” and designer drugs Alcoholic disease Excessive consumption of acidic foods and drinks Nighttime baby bottle feeding with acidic beverages Oral hygiene practices: frequent toothbrushing, abrasive oral care products

Prevention Loss of tooth surface is a multifactorial process and education is the first step in the line of defense.4 Loss of tooth surface is a multifactorial process and education is the first step in the line of defense.5

Interactions between Behavioral and Biological Factors
Dental Erosion: Diagnosis/Management Dynamics of Dental Erosion21 Before During After Time (Frequency) Interactions between Behavioral and Biological Factors The dynamics of dental erosion involve the interactions between behavioral and biological factors across the time continuum. As demonstrated by Dom Zero et al 21. Lussi A, Kohler N, Zero D, et al.

Dental Erosion: Management/Etiological Factors
Awareness/Association/Education Dietary factors15 Avoid radical changes in dietary habits Reduce acid exposure by reducing frequency and contact time of acid Avoid acidic foods and drinks late at night Avoid high-acidity liquids via baby bottle for infants Avoid low pH values in food and beverages Dietary factors15 Radical changes in dietary habits should be avoided Reduce acid exposure by reducing frequency and contact time of acid Avoid acidic foods and drinks late at night For infants, avoid high-acidity liquids via baby bottle pH values in food and beverages

Dental Erosion Management/Etiological Factors
Awareness/Association/Education Dietary factors: generally, a pH value of 5.5 or lower is capable of softening the surface of enamel in only a few minutes.3 Dietary factors: generally, a pH value of 5.5 or lower is capable of softening the surface of enamel in only a few minutes.3 3. Strassler HE, Drisko CL, Alexander DC.

Awareness/Association/Education Behavioral/habits15 Do not hold or swish acidic drinks in your mouth Avoid sipping acidic drinks—use a straw Avoid toothbrushing immediately after an erosive challenge (vomiting, acidic diet) Avoid toothbrushing immediately before an erosive challenge, as the acquired pellicle provides protection against erosion Use a soft toothbrush Behavioral/habits15 Do not hold or swish acidic drinks in your mouth Avoid sipping acidic drinks—use a straw Avoid toothbrushing immediately after an erosive challenge (vomiting, acidic diet) Avoid toothbrushing immediately before an erosive challenge, as the acquired pellicle provides protection against erosion Use a soft toothbrush

Awareness/Association/Education Behavioral/Habits15 Use a low-abrasion fluoride-containing toothpaste; high-abrasive toothpaste may destroy pellicle Avoid toothpastes or mouthwashes with too-low pH After acid intake, stimulate saliva flow with chewing gum or lozenges Use chewing gum to reduce postprandial reflux Refer patients or advise them to seek appropriate medical attention when intrinsic causes are involved Behavioral/habits15 Use a low-abrasion fluoride-containing toothpaste; high-abrasive toothpaste may destroy pellicle Avoid toothpastes or mouthwashes with a too-low pH After acid intake, stimulate saliva flow with chewing gum or lozenges Use chewing gum to reduce postprandial reflux Refer patients or advise them to seek appropriate medical attention when intrinsic causes are involved Postprandial: after a meal (source: Dorland’s Medical Dictionary)

Awareness/Association/Education Gastroesophageal Origin22 Heartburn and other symptoms of reflux Regurgitation Dysphagia Asthma Rumination Eating disorders (anorexic or bulimia) Gastroesophageal Origin22 Heartburn and other symptoms of reflux Regurgitation Dysphagia Asthma Rumination Eating disorders (anorexic or bulimia) Definitions (source: Dorland’s Medical Dictionary) Heartburn: an esophageal symptom consisting of a retrosternal [behind the sternum] sensation of warmth or burning occurring in waves and tending to rise towards the neck; it may be accompanied by a reflux of fluid into the mouth (water brash). It is often associated with gastroesophageal reflux. Regurgitation: to flow in the opposite direction from normal Dysphagia: difficulty in swallowing Asthma: recurrent attacks of paroxysmal dyspnea [shortness of breath], with airway inflammation and wheezing due to spasmodic contraction of the bronchi. Some cases are allergic manifestations in sensitized persons; others are provoked by factors such as vigorous exercise, irritant particles, psychological stresses, and others. Rumination: in ruminants [eg, cows], the casting up of food (called "cud") out of the rumen and chewing of it a second time. In humans, the regurgitation of food after almost every meal, part of it being vomited and the rest being swallowed. Eating disorders: 1. Anorexia: more properly, anorexia nervosa. An eating disorder primarily affecting females, usually with onset in adolescence, characterized by refusal to maintain a normal minimal body weight, intense fear of gaining weight or becoming obese, and a disturbance of body image resulting in a feeling of being fat or having fat in certain areas even when extremely emaciated, undue reliance on body weight or shape for self-evaluation, and amenorrhea. Associated features often include denial of illness and resistance to psychotherapy, depressive symptoms, markedly decreased libido, and obsessions or peculiar behavior regarding food, such as hoarding. The disorder is divided into two subtypes, a "restricting" type, in which weight loss is achieved primarily through diet or exercise, and a "binge-eating/purging" type, in which binge eating or purging behavior also occur regularly. 2. Bulimia: episodic binge eating usually followed by behavior designed to negate the excessive caloric intake, most commonly purging behaviors such as self-induced vomiting or laxative abuse but sometimes other methods such as excessive exercise or fasting.

Awareness/Association/Education Medicinal factors associated with dental erosion23 Some medicines can potentially induce GERD theophyline progesterone anti-asthmatics calcium channel blockers Aspirin (especially in chewable format) Medicines that decrease salivary flow antihistamines anticholinergics antidepressants antipsychotics Medicinal factors associated with dental erosion23 Some medicines can potentially induce GERD theophyline progesterone anti-asthmatics calcium channel blockers Aspirin (especially in chewable format) Medicines that decrease salivary flow antihistamines anticholinergics antidepressants antipsychotics Definition (source: Dorland’s Medical Dictionary) GERD: gastroesophageal reflux disease. Reflux of the stomach and duodenal contents into the esophagus, particularly in the distended stomach postprandially, as a chronic pathological condition.

Dental Erosion/Toothwear
Prevention is better than a cure… Education is the key!

Dental Erosion/Tooth Wear—References
1. Oral Health for Children: Patient Education Insert. Compend Contin Educ Dent. 2005;26(5 Suppl 1):Insert. 2. Sturdevant JR, Lundeen TF, Sluder TB Jr. Clinical significance of dental anatomy, histology, physiology, and occlusion. In: Robertson TM, Heymann HO, Swift EJ Jr, eds. Sturdevant’s Art and Science of Operative Dentistry. 4th ed. Mosby: St. Louis, MO; 2002:13-61. 3. Strassler HE, Drisko CL, Alexander DC. Dentin hypersensitivity: its inter-relationship to gingival recession and acid erosion. Inside Dentistry. 2008;29(5 Special Issue):3-4. 4. Robertson TM, Lundeen TF. Cariology: the lesion, etiology, prevention, and control. In: Robertson TM, Heymann HO, Swift EJ Jr, eds. Sturdevant’s Art and Science of Operative Dentistry. 4th ed. Mosby: St. Louis, MO; 2002: 5. Tooth Erosion in Children—US Perspective. Inside Dentistry. 2009;5(3 Suppl):8. 6. Imfeld T. Dental erosion. Definition, classification and links. Eur J Oral Sci. 1996;104(2 (Pt 2)): 7. ten Cate JM, Imfeld T. Dental erosion. Summary. Eur J Oral Sci. 1996;104(2 (Pt 2)): 8. The dental cosmos: a monthly record of dental science. Perioscope. 1875;17(2): 9. ten Cate JM, Imfeld T. Dental erosion. Preface. Eur J Oral Sci. 1996;104(2 (Pt 2)):149. 10. Jaeggi T, Lussi A. Prevalence, incidence, and distribution of erosion. In: Lussi A, ed. Dental Erosion: From Diagnosis to Therapy. Basel, Switzerland: Karger; 2006: Whitford GM. Monographs in Oral Science; vol. 20. 11. Ganss C, Klimek J, Giese K. Dental erosion in children and adolescents: a cross-sectional and longitudinal investigation using study models. Community Dent Oral Epidemiol. 2001;29(4): 12. Truin GJ, van Rijkom HM, Mulder J, van’t Hof MA. Caries trends among 6- and 12-year-old children and erosive wear prevalence among 12-year-old children in The Hague. Caries Res. 2005;39(1):2-8.

Dental Erosion/Tooth Wear—References
13. Dugmore CR, Rock WP. The prevalence of tooth erosion in 12-year-old children. Br Dent J. 2004;196(5): 14. Kidd EAM, Mejare L, Nyvad B. Clinical and radiographic diagnosis. In: Fejerskov O, Kidd EAM, eds. Dental Caries: The Disease and its Clinical Management. Copenhagen: Blackwell Munksgaard; 2003: 15. Lussi A, Hellwig E. Risk assessment and preventative measures. In: Lussi A, ed. Dental Erosion: From Diagnosis to Therapy. Basel, Switzerland: Karger; 2006: Whitford GM. Monographs in Oral Science; vol 20. 16. Lussi A. Erosive toothwear: a multifactorial condition of growing concern and increasing knowledge. In: Lussi A, ed. Dental Erosion: From Diagnosis to Therapy. Basel, Switzerland: Karger; 2006:1-8. Whitford GM. Monographs in Oral Science; vol. 20. 17. Gandara BK, Truelove EL. Diagnosis and management of dental erosion. J Contemp Dent Pract. 1999;1(1):16-23. 18. Lussi A, Jaeggi T. Chemical factors. In: Lussi A, ed. Dental Erosion: From Diagnosis to Therapy. Basel, Switzerland: Karger; 2006: Whitford GM. Monographs in Oral Science; vol. 20. 19. Hara AT, Lussi A, Zero DT. Biological factors. In: Lussi A, ed. Dental Erosion: From Diagnosis to Therapy. Basel, Switzerland: Karger; 2006: Whitford GM. Monographs in Oral Science; vol 20. 20. Zero DT, Lussi A. Behavioral factors. In: Lussi A, ed. Dental Erosion: From Diagnosis to Therapy. Basel, Switzerland: Karger; 2006: Whitford GM. Monographs in Oral Science; vol 20. 21. Lussi A, Kohler N, Zero D, et al. A comparison of the erosive potential of different beverages in primary and permanent teeth using an in vitro model. Eur J Oral Sci. 2000;108(2): 22. Bartlett D. Intrinsic causes of erosion. In: Lussi A, ed. Dental Erosion: From Diagnosis to Therapy. Basel, Switzerland: Karger; 2006: Whitford GM. Monographs in Oral Science; vol 20. 23. Hellwig E, Lussi A. Oral hygiene products and acid medicines. In: Lussi A, ed. Dental Erosion: From Diagnosis to Therapy. Basel, Switzerland: Karger; 2006: Whitford GM. Monographs in Oral Science; vol 20.

Dental Erosion—Tooth Wear
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