Dental Erosion

Dental erosion is the irreversible loss of tooth surface by acid or chelation without bacterial involvement. It produces smooth, shallow, dished defects on enamel and then dentine that progress as the acid exposure continues, and it is distinct from caries, abrasion and attrition though the processes often combine.

• Intrinsic acid (gastric): gastro oesophageal reflux disease, hiatus hernia, chronic vomiting (hyperemesis, bulimia nervosa, alcohol use disorder, rumination), pregnancy related vomiting, and gastroparesis.
• Extrinsic acid: carbonated and sports drinks, fruit juices and citrus fruit, vinegar, pickles, wine and cider, fruit teas, vitamin C tablets, acidic medicines (chewable aspirin, iron tonic, hydrochloric acid supplements), swimming pool water with low pH, and occupational exposure to acid fumes (battery and chemical workers).
• Modifying factors: low saliva flow (dry mouth, medicines, Sjogren syndrome), poor salivary buffering, tooth brushing soon after acid exposure, abrasive toothpaste, and bruxism.
• Prevalence: 20 to 45 percent of adults show some erosive wear, and up to 30 to 50 percent of children and adolescents; more common with a diet high in acidic drinks.

• Early: smooth, glazed, silky enamel with loss of surface texture and perikymata; incisal edges become translucent and thin.
• Later: cupping of molar cusps and incisal edges, dentine exposure with yellow colour, wear on the occlusal surfaces with fillings standing proud of the surrounding tooth, shortened teeth, and flat shallow defects on the buccal gingival margins.
• Pattern clues: palatal surfaces of upper incisors and occlusal surfaces of lower molars suggest intrinsic acid (reflux or vomiting); labial and buccal surfaces of upper teeth and cervical wear suggest extrinsic acid.
• Symptoms: sensitivity to hot, cold and sweet food, aesthetic concern, rough feeling of the teeth, and eventually pulp exposure and pain.
• General history: heartburn, regurgitation, nocturnal cough, vomiting, binge eating, dieting, alcohol, medicines, dry mouth, occupation, hobbies (swimming, wine tasting).

• Clinical examination and history, with a dietary analysis (24 to 72 hour diary of drinks and acidic foods, timing and mode of consumption).
• Grade severity with a validated erosion index (for example the Basic Erosive Wear Examination, scoring each sextant 0 to 3).
• Clinical photographs, study models and intraoral scans to monitor progression; salivary flow rate (unstimulated flow under 0.1 mL/min indicates dry mouth) and buffering capacity.
• Medical assessment when intrinsic acid is likely: reflux symptoms, upper endoscopy if alarm features (dysphagia, weight loss, anaemia, vomiting blood) or poor response to treatment; sensitive screen for eating disorders (SCOFF questionnaire).
• Differentials: attrition (wear from tooth-to-tooth contact with flat polished facets), abrasion (from brushing or habit), abfraction, caries, amelogenesis imperfecta and dentinogenesis imperfecta, fluorosis, and tetracycline staining.

Identify and control the acid source

• Reduce the frequency of acidic foods and drinks to no more than 4 times daily and restrict to mealtimes; do not sip or swish acidic drinks; use a straw placed toward the back of the mouth; drink water or milk after acidic drinks; eat cheese or milk after acidic food.
• Do not brush teeth for at least 60 minutes after acid exposure or vomiting; instead rinse with water or a fluoride mouthwash (0.05 percent sodium fluoride), or a sodium bicarbonate rinse (1 teaspoon in a glass of water), and smear fluoride toothpaste with a finger.
• Chew sugar free gum for 10 minutes after meals to stimulate saliva.

Reflux and vomiting

• Gastro oesophageal reflux: lifestyle measures (avoid late meals, raise the bed head, weight loss) and omeprazole 20 mg orally daily before breakfast for 4 to 8 weeks, then the lowest dose that controls symptoms (review need at 3 months).
• Eating disorders: sensitive discussion, referral for cognitive behavioural therapy for bulimia nervosa, and fluoxetine 60 mg daily for bulimia nervosa where indicated by a specialist; dental care continues in parallel.
• Hyperemesis in pregnancy: small frequent meals, antiemetics (for example doxylamine pyridoxine or ondansetron 4 mg as prescribed), and rinsing with water or a fluoride mouthwash after each episode of vomiting.
• Alcohol use disorder: offer treatment and thiamine.

Protect and strengthen enamel

• Fluoride toothpaste 1350 to 1500 ppm twice daily with a soft brush and minimal rinsing; low abrasivity toothpaste (stannous fluoride toothpaste forms a protective layer).
• High risk patients: high fluoride toothpaste 5000 ppm on prescription, fluoride mouthwash 0.05 percent daily, professional fluoride varnish 22,600 ppm every 3 to 6 months, and casein phosphopeptide amorphous calcium phosphate paste (applied twice daily) for remineralisation.
• Treat dry mouth: sip water, saliva substitutes, review medicines (for example anticholinergics, antidepressants, antihistamines), pilocarpine 5 mg orally three times daily for severe hyposalivation if not contraindicated.
• Night guard for bruxism.

Restorative care

• Early lesions: monitor with photographs and models every 6 to 12 months.
• Sensitivity: desensitising toothpaste (potassium nitrate 5 percent or stannous fluoride) and fluoride varnish.
• Established loss: adhesive composite resin build up, glass ionomer for cervical lesions, veneers, onlays or crowns, performed once the acid source has been controlled for at least 6 months to avoid repeat failure.

Follow up

• Dental review every 3 to 6 months; re-examine the diet, adherence, and reflux or eating disorder treatment; measure wear using the same index.

Special groups

• Children: primary teeth have thinner enamel and wear faster; limit juice to mealtimes and diluted, avoid sippy cups with acidic drinks, supervise brushing with 1000 to 1450 ppm fluoride toothpaste, and investigate reflux or vomiting.