JADA Continuing Education
A New Look at Erosive Tooth Wear in Elderly People
David Bartlett, BDS, PhD, FDS RCS
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ABSTRACT
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Background. The author describes the clinical appearance of and the outcomes associated with erosive tooth wear, particularly that in older people.
Types of Studies Reviewed. The author conducted a traditional clinical review that was based on a synopsis of the current literature on dental erosion. He found that intrinsic and extrinsic acids are known to be associated with acid erosion and tooth wear. He also explored the etiology and pathogenesis of tooth wear and compared the longevity of restorations to the option of monitoring and preventing tooth wear. He found that preventive measures, which included limiting the frequency of acid exposure and using fluoride toothpastes and dentin-bonding agents, could prolong tooth life.
Results. Tooth wear and acid erosion are common clinical findings in patients of all ages. The results of tooth wear can cause significant damage to teeth, which can require complex and costly prosthodontic treatment.
Clinical Implications. Diagnosing the cause of a patient’s tooth wear can help prevent further damage.
Key Words: Acid erosion; diet; tooth wearAbbreviations: GERD: Gastroesophageal reflux disease
The importance of acids in the etiology of tooth wear has been recognized in Europe and increasingly in North America. Tooth wear is part of the normal aging process, but, in most people, the rate of tooth wear does not compromise the longevity of the teeth. Approximately 7 percent of subjects in a 1996 study had exposure of secondary dentin and the pulp that justified operative intervention.1
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CLASSIFICATION OF TOOTH WEAR
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The definitions of types of tooth wear include attrition as wear of tooth against tooth, abrasion as wear of tooth against other surfaces, erosion caused by acids and the theoretical concept of abfraction. The clinical interpretation of these definitions, however, varies among dental professionals in different countries.2 Erosion occurs on smooth (facial, lingual, palatal), occlusal and incisal tooth surfaces. The appearance of erosive lesions is distinctive in that they are hollowed- or cupped-out lesions that gradually link to form bigger lesions. Figures 1
and 2 show examples of erosion on adult teeth. The term "erosion" generally is understood and accepted by most patients and dentists; however, there are some who prefer the term "corrosion."3
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Figure 1. Erosion of the facial surfaces of maxillary incisors. The patient had a dietary habit of holding oranges against his teeth, which caused the enamel to be removed.
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Figure 2. Erosion on the palatal and lingual surfaces of the maxillary anterior teeth of a 60-year-old man who had recurrent regurgitation of his stomach contents after chronic acid reflux.
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The role of abfraction in tooth wear remains controversial. Theoretically, it involves flexure and distortion of the tooth at the cervical margin, which predisposes the area to erosion or abrasion.4 Although the theoretical concept has gained some support from clinicians, the clinical and laboratory evidence remains unconfirmed. In a recent critical review, Bartlett and Shah5 found a few laboratory studies that supported the concept of abfraction, but there was no clinical evidence to suggest that it exists. Further research is needed to investigate this concept.
Attrition produces teeth with flattened and smooth incisal and occlusal surfaces and is associated with para-functional activity.6 The cause of abrasion is less clearly understood. A laboratory investigation predicted that it would take 2,500 years of using a toothbrush alone to remove 1 millimeter of enamel from a tooth, and it would take 100 years of using a toothbrush with toothpaste to remove 1 mm of enamel.7 Combining toothpaste with acid produces the same amount of wear in two years.8 Therefore, it is unlikely that abrasion alone is damaging to teeth.8 Only when abrasion is combined with acids is the damage to teeth more significant.
The sources of acid generally are intrinsic or extrinsic.9,10 Extrinsic sources commonly are found in the diet (for example, citrus fruits and citrus drinks). It appears that liquids with higher titratable acidity (buffering capacity) are associated with greater erosive potential.11 Therefore, although carbonated beverages have a low pH, the amount of saliva needed to neutralize a carbonated beverage is less than that needed to neutralize a citrus fruit such as a lemon (Box).12 Intrinsic acids from the stomach that are regurgitated or vomited will cause dental erosion10 and may occur in patients who have eating disorders, have alcoholism or experience regurgitation of gastric juice. Eating disorders are relatively uncommon; some estimates suggest that the prevalence is as low as 0.6 to 1.6 per 100,000.10 Although alcoholism is a relatively common source of tooth erosion and depends on the amount of alcohol consumed, its impact on teeth may be similar to that of other intrinsic causes.13 The most common cause of intrinsic erosion is related to gastroesophageal reflux disease (GERD) and regurgitation,14 since GERD affects up to 60 percent of people at some point in their lives.15 Owing to the low pH and titratability of gastric juice, the destruction to the enamel and dentin usually is more severe than that caused by extrinsic sources. Consequently, complex prosthodontic intervention often is required.
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PREVALENCE
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Most of the prevalence studies in Europe and North America have involved children rather than adults and indicated that the prevalence of wear on enamel is common (up to 60 percent involvement), while the prevalence of exposed dentin varies between 2 to 10 percent.16–18 One study reported similar observed levels of tooth wear and erosion in children seen at dental schools at New York University in New York City and Edinburgh University in Scotland.19 There are, however, comparatively fewer data for adults, but the levels of severe dentin exposure still average about 10 percent.1,20 However these data are interpreted, tooth wear has become part of dentists’ regular assessments, and providing information to patients about tooth wear is becoming more important.
Since tooth wear is part of the normal aging process, it is not surprising to find that older patients have more tooth wear. The results from one study suggested that the proportion of pathological wear in people 65 years and older was more than three times greater than that observed in people aged 26 to 35 years.1 If the data observed in children are typical, as children age, the amount of wear either will remain the same or worsen. By the time the children are 60 years old, the management of their care may be a restorative challenge. Therefore, it is important to consider what dentists can do to prevent tooth wear from developing and what treatment options exist.
In patients with caries, only individual teeth are affected, while in patients who experience tooth wear—particularly that involving erosion—many, if not most, of their teeth can be involved. Therefore, a restorative treatment plan for patients with tooth wear normally is more complex and expensive than that for patients with caries. In the most severe cases, changes to the patient’s vertical dimension are required and more complex prosthodontic treatment is needed (Figure 3). Ideally, dentists should recognize the signs of tooth wear early and start preventive measures. For older patients, an added complication is that their tolerance for complex restorative care diminishes and their ability to maintain oral health can be compromised, particularly as a result of reduced saliva output.
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Figure 3. A 75-year-old woman who wanted to improve the appearance of her teeth. A. The labial view of her worn teeth. B. The palatal view of worn teeth.
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RESTORATIVE DECISION MAKING
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An important principle in assessing the need for restorative treatment of worn teeth is the likely outcome of any restoration. Direct composites used to restore worn anterior teeth have provided a reasonable longevity of about three to five years.21,22 A recent study showed that 50 percent of direct or indirect composites used to treat tooth wear failed within two years.23 Even less research is available on the longevity of crowns used to restore worn teeth, but perhaps 10 years is reasonable considering research on unworn teeth.24
Dentists must make difficult clinical decisions when treating patients 75 years and older who have severe levels of tooth wear. They should determine whether the restoration is likely to survive the patient’s lifetime and whether the complexity and the cost of care makes intervening with the restoration effective. There is an increasing body of opinion that states that the rate of progression of tooth wear is slow.25–27 Therefore, if the rate of wear is not likely to result in the loss of the tooth, perhaps dentists should monitor tooth wear rather than treat it operatively.
Each clinical decision depends on the patient’s needs, but expecting an older patient to undergo prolonged and complex care, with the realization that the restoration may not necessarily prolong the life of the dentition, is questionable. A simpler, more pragmatic plan may be for the dentist to monitor the patient’s tooth wear and provide pain relief and endodontic treatment if necessary but not restore the structure or appearance of the teeth with complex prosthodontic restorations.
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PREVENTION
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The role of prevention is vital in maintaining the integrity of the teeth. Even when the levels of tooth wear are less severe, dentists should remember that the progression of tooth wear often is related to acids. A clinical indicator for active tooth wear is the appearance of worn teeth. Stained teeth suggest that the acid erosion and wear are inactive, whereas stain-free teeth suggest that the erosive process is active.6 The rationale behind this is that persistent acid exposure removes the outer layer of enamel or dentin, creating a stain-free surface. The presence of stains indicates that the wear process is inactive, as sufficient time has passed to allow dietary stains to be taken up onto the tooth surface. Another clinical indicator is the presence of dentin sensitivity, which suggests that the erosive process is active, as it is more likely to occur when acids are involved with the etiology.28
Dentists’ dietary advice to patients should not be that patients eliminate acids from their diet. It is more important for dentists to encourage patients to consume acidic foods in moderation. For example, acid intake should occur at mealtimes, much like sugar intake for caries control. Research suggests that acids from intrinsic or extrinsic acids are buffered within a few minutes and more quickly than those observed with dental caries.29 Therefore, it is the frequency of acid exposure and the length of time that the acids are present in the mouth that are important. A patient’s detailed diet diary can be helpful to the dentist in identifying acids present in the diet; for example, it is not uncommon for patients to describe unusual dietary habits, such as sucking lemons or eating one orange over the course of a day.
The role of fluoride has been shown to have the potential to harden enamel surfaces and encourage remineralization.30,31 On the basis of this evidence, dentists should suggest that patients not brush their teeth immediately after consuming acids but instead wait for at least 30 minutes, as studies have shown that the time needed for softened enamel and dentin to reharden after an erosive challenge ranges from two to 30 minutes.30,31 Therefore, toothbrushing after an erosive challenge would produce more tooth wear. Alternatively, brushing teeth before meals might be more effective. For most patients who do not have tooth wear, the timing of toothbrushing probably is not relevant. But for patients with dentin sensitivity or erosive tooth wear, they should consider the timing of acid intake and toothbrushing. Dentists can recommend fluoride dentifrices with neutral pH that help to reharden softened enamel.
A recent investigation suggested that the application of a dentin-bonding agent or sealant to worn or eroded teeth may provide some protection.27 In this clinical study, researchers applied dentin-bonding agent to alternate teeth of subjects with severe palatal dental erosion, while the uncoated teeth acted as controls. Most of the dentin-bonding agent had worn away after three months, but some of it remained in place for up to six months. The rate of tooth wear on the protected teeth was one-half that of the unprotected teeth.
Dentists also may consider using fissure sealants for patients for whom dentin-bonding agents seem to be ineffective. Fissure sealants used to coat the eroded surfaces of maxillary anterior teeth provided protection for a longer period than did dentin-bonding agents.32
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CONCLUSIONS
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The decision to restore worn or eroded teeth depends on the patient’s needs and the state of the teeth and supporting tissues. Prevention is an important contributor to the survival of teeth.
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FOOTNOTES
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Dr. Bartlett is a professor and the head, Prosthodontics, King’s College, London Dental Institute, Floor 25, Guy’s Tower, London Bridge, London, England SE19RT, e-mail "david.bartlett{at}kcl.ac.uk". Address reprint requests to Dr. Bartlett.
An additional example of erosion on adult teeth is available with this article as posted on JADA Online ("http://jada.ada.org"). Interested readers may link to this article online, then click on the link in the "Supplemental Data" box.
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REFERENCES
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- Bartlett DW, Phillips KM, Smith BGN. A difference of perspective: the North American and European interpretations of tooth wear. Int J Prosthodont 1999;12(5):401–8.[Medline]
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- Lee WC, Eakle WS. Possible role of tensile stress in the etiology of cervical erosive lesions of teeth. J Prosthet Dent 1984;52(3):374–9.[Medline]
- Bartlett DW, Shah PA. A critical review of non-carious cervical (wear) lesions and the role of abfraction, erosion, and abrasion. J Dent Res 2006;85(4):306–12.[Abstract/Free Full Text]
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- Walton TR. A 10-year longitudinal study of fixed prosthodontics: clinical characteristics and outcome of single-unit metal-ceramic crowns. Int JProsthodont 1999;12(6):519–26.
- Bartlett DW, Palmer I, Shah P. An audit of study casts used to monitor tooth wear in general practice. Br Dent J 2005;199(3):143–5.[Medline]
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ABSTRACT
CLASSIFICATION OF TOOTH WEAR
