Nevertheless, dietary factors are the most common etiologic factor implicated in the development of dental erosion.³ Fruits, fruit juices and candies with high concentrations of citric acid,^9,13,14 carbonated beverages (in which citric and phosphoric acids, not carbonic acid, are the cause of erosion^2,9,15 and vinegar (acetic acid) associated with pickled foods⁹ are the usual extrinsic dietary instigators of dental erosion.

Infrequently reported is the acid erosion caused by wine. It is my impression that with changes in lifestyles, the consumption of wine has increased. The pH of wine has been reported to range from 3.0 to 3.8,^5,16,17 with white wine being slightly more acidic than red wine.^5,18 Wine derives its acidity mostly from its contained tartaric and malic acids and from smaller concentrations of citric and succinic acids.^13,19 Because the critical point at which enamel dissolves is reported to be a pH of 5.0 to 5.7,^13,19–22 wine can be a serious player in dental erosion. The salivary concentration of calcium and phosphate normally is supersaturated in relation to enamel hydroxyapatite. An acid challenge results in undersaturation of these salivary salts, and tooth demineralization with softening of dental enamel occurs.^13,15,23 The altered enamel now becomes susceptible to wearing away by masticatory forces and toothbrushing.^24,25

Only recently have foreign reports appeared concerning wine-incited dental erosions,^{5,7,15–19,26} but I could find none in a search of the U.S. dental literature. Because wine gradually has become part of society’s diet and because dentists are in the key position to note the dental damage it can cause, I am providing this case report to alert the dental profession to the fact that wine is a cause of erosion, as well as to present the dental manifestations of wine’s excessive and inappropriate use.

	CASE REPORT

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A 56-year-old woman was referred to Columbia University’s Salivary Gland Center in New York City because her dentist had noted an excessive loss of tooth structure, particularly the enamel. He was concerned that altered salivary volume or composition might be implicated in the problem.

Because the patient would sip the wine gradually over a prolonged three-hour period, there was sufficient time for the wine’s acids to act on the enamel.

A medical history indicated that the patient was in excellent health. Her medications included the daily use of lisinopril for hypertension and chlorpheniramine and pseudoephedrine for nasal congestion.

Intraorally, the mucosa appeared normally moist. All salivary ducts were patent with a free and clear salivary flow, which became evident when the salivary glands were aggressively milked. The most eye-catching intraoral abnormality was the obvious deterioration of dental hard structures, particularly the enamel. Irregular enamel loss was most advanced on the occlusal aspects of the premolars and molars, where masticatory contact was pronounced (Figures 1 through 4). The irregular pattern of wear was to some extent compensated for by the placement of restorations. In addition, the buccogingival surfaces of these posterior teeth had a marked yellowish discoloration.

View larger version (83K): [in this window] [in a new window]   Figure 1. Maxillary right side. Loss of occlusal enamel with exposed dentin encircled by peripheral white enamel rim in teeth nos. 5, 6 and 7. Resin-based composite restorations are present in teeth nos. 5, 6 and 7.

View larger version (89K): [in this window] [in a new window]   Figure 2. Maxillary left side. Loss of occlusal enamel with dentin exposure and presence of peripheral enamel rim in teeth nos. 11 and 13. Note the peephole effect, or "cupping," on the cusps of tooth no. 14.

View larger version (73K): [in this window] [in a new window]   Figure 3. Mandibular right side. Loss of occlusal enamel and exposure of dentin (teeth nos. 29 and 30). The apparent amalgam projection results from loss of adjacent dental structure in tooth no. 30. Note marked yellow discoloration along buccogingival aspect of teeth nos. 29 and 30.

View larger version (69K): [in this window] [in a new window]   Figure 4. Mandibular left side. Loss of occlusal enamel with dentin exposure and presence of white enamel rim in teeth nos. 18, 19, 20 and 22. Apparent restoration projections are on teeth nos. 18 and 19. Some yellow discoloration of buccogingival surfaces on teeth nos. 19 and 20 can be noted.

Further questioning regarding the patient’s diet revealed that she had been drinking three-fourths to a full bottle (750 milliliters) of white wine each evening for the past 34 years. More importantly, she had the habit of sipping the wine over a three-hour period after dinner and then retiring without cleaning her mouth. Such imbibing of wine inevitably points to a diagnosis of dental erosion caused by the acidity of wine.

	DISCUSSION

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Most cases of wine-damaged teeth have been reported in wine tasters and wine merchants.^{4,5,16,19,21,26} Wine tasters sample five to 50 wines each day, holding the wine in their mouth from 15 to 60 seconds,^17,19 which is sufficient time for widespread erosion of all teeth to occur from the sipping and swilling if no other factors intervene. This frequent and long exposure to an acid pH makes the teeth more likely to be eroded than if the person rapidly swallowed the wine,²⁷ or if food with its increased salivary production and physical detergent effect served to lessen the wine’s dental contact time.

And so it was with the patient in the case report. The patient admitted to drinking approximately 562 to 750 mL of wine after each nightly meal for the past 34 years. Because she would sip the wine gradually over a prolonged three-hour period, there was sufficient time for the wine’s acids to act on the enamel. The problem of increased dental exposure was accentuated by several other factors. Food, with its resulting salivary stimulation and detergent effect, was not eaten after dinner, resulting in a failure to flush and physically clear the wine from the teeth. The patient’s oral hygiene practices also contributed to the problem because she did not brush her teeth or use a mouthwash before retiring, thus increasing the dental contact time of any residually retained wine while she slept. To some extent, the failure to brush was fortunate because an intensified period of tooth demineralization and softening rapidly occurs after acid exposure. Dental enamel loss from brushing abrasion will be increased because sufficient time for remineralization will not have passed.^23,25 Another factor of concern was the patient’s medications. Both the antihypertensive medication and the antihistamine are xerostomic. These medications amplified the decreased salivation physiologically normally present when a food stimulus is absent or during sleep and caused a more profound failure of salivary lavage.

Saliva with its buffering capacity and its ability to form a protective enamel pellicle^7,15,18 can control dental decalcification. This physiological protection fails when saliva is overwhelmed by large quantities of a substance with a low pH or when a decreased salivary production occurs. Thus, the key to this patient’s susceptibility to dental erosion can be found in the manner and timing of her wine drinking, with her medications and oral hygiene practices adding further insult.

Close examination of the patient’s teeth revealed some classic effects of the protracted wine sipping. During sipping and holding the wine in the mouth, the occlusal aspects of the posterior teeth were contacted and affected readily, and the enamel was lost extensively (Figures 1 through 4). Exposure of the yellow-colored dentin was most pronounced where the physical stresses of mastication resulted in the removal of the acid-softened enamel. I saw cupping,^{2,15,16,19,26} a hollowed-out area that develops when softer exposed dentin dissolves faster than the surrounding enamel, on some teeth (Figure 2). Such a peephole configuration initially develops from point contact during mastication with the cuspal height of an opposing tooth. My examination of the occlusal surfaces of the posterior teeth also revealed a frosty white rim of decalcified enamel encircling the exposed occlusal dentin (Figures 1 through 4). Additionally, what appeared to be extruded restorations actually was dental hard tissue loss adjacent to the restorations (Figures 3 and 4).

The observed increased yellow hue of the buccogingival aspects of the posterior teeth, most marked on the mandibular teeth (Figures 3 and 4), was derived from enamel loss, which makes the underlying yellow dentin more visible. Gravity plays a role through the increased wine contact with mandibular teeth compared with maxillary teeth. The softened enamel, which normally is thin along the gingival tooth surfaces, will be further thinned by toothbrush abrasion. The yellow dentin then will be closer to the surface and more visible.

Despite the extensive dentin exposure, the patient had no subjective pain complaints. The enamel’s destruction by wine is a slow process. Consequently, secondary dentin has the opportunity to form and protect the pulp from thermal irritations.²⁸

	TREATMENT

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Treatment involves a variety of approaches. Obviously, wine drinking should be discouraged. If it is continued, however, it should be restricted for use only during the main meal. Fluorides in the form of toothpaste, mouthwash and topical applications are to be encouraged. Alkaline mouthwashes are helpful.^9,16,19 Instruction in the proper method of brushing with a soft-bristled toothbrush should be given. After exposure to the acidic food, brushing should be delayed for at least an hour so that tooth remineralization—a salivary function—can occur.^19,23,25,27 Restorations should be placed as deemed necessary by the dentist.

Besides repairing the dental damage wrought by the acidic wine diet and offering instruction regarding prevention of further damage, the dental practitioner has another important obligation. Dental erosion caused by wine consumption usually is derived from extensive use of wine. Liver damage from the wine’s 12 to 14 percent alcohol content can be considered an expected consequence when large volumes are consumed. Medical referral for a liver assessment is indicated in such cases. I made such a referral to the patient’s internist.

	CONCLUSIONS

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The inappropriate use of wine can lead to extensive dental erosions. Therefore, wine must be considered when assessing dietary causes of such erosions.

Dentists are in a unique position to make a diagnosis of wine-initiated dental destruction and to institute the necessary preventive and therapeutic measures.

Liver damage must be suspected when large quantities of wine are consumed. Referral to an internist is indicated.