Tooth wear is a natural part of ageing and so the extent of any visible wear must be judged against the patient’s age to determine whether or not the tooth wear is pathological or physiological. The latest adult dental health survey suggests that over three-quarters of adults (77%) have some tooth wear and that moderate tooth wear has increased, with the greatest increases in younger adults. National surveys suggest that tooth wear is increasing in adolescents. Tooth wear is generally a relatively slow process and should be picked up at regular dental visits.
Tooth wear is the loss of tooth structure involving mechanical and chemical factors leading to attrition, abrasion and/or erosion. Mechanical wear involves physical contact with another material or object such as a brush or erosive paste or an opposing surface leading to attrition and/or abrasion. Erosion is the chemical loss of hard tissue through exposure to acids (extrinsic and/ or intrinsic), which are of nonbacterial origin, and today this is the branch of tooth wear I will focus on.
Erosion plays a role in most forms of tooth surface loss. Extrinsic sources of acid include dietary sources such as fruits, fruit juices and fizzy drinks, and supplements such as vitamin C and iron can also contribute to erosion. Sour sweets are very acidic and are usually sucked for several minutes, leaving teeth weakened and enamel eroded. Swimming pool water containing chlorine can also lead to the dissolution of enamel, and professional swimmers have been shown to have high levels of tooth wear. Many alcoholic drinks can also lead to tooth erosion, with wines being one of the most acidic, and if sipped over a long period of time they can leave teeth very susceptible to dissolution. Cocktails which mix alcoholic spirits and fizzy drinks can also be very bad for erosion, as well as containing high levels of sugar – a double hit!
Alcoholism is becoming more and more of a major issue in the United Kingdom. In 2015, the ‘Drinkaware alcohol survey’ showed that 86% of men drink and 12% have more than 14 units per week. These statistics are always on the rise and have contributed to the increasing prevalence of acid erosion. Not only is alcohol an extrinsic source of acid, but it can lead to an intrinsic acid attack as during binge drinking sessions people are likely to throw up their stomach acid. This two-way erosion can lead to massive dissolution on several tooth surfaces and leave the teeth in a very weak state. Excessive alcohol consumption, as well as smoking and obesity which are also on the rise in the UK, are also predisposing factors for Gastro-oesophageal reflux disease (GORD) which can lead to regular episodes of stomach acid entering the oral cavity.
Another intrinsic cause of acid dissolution of teeth is the eating disorder Bulimia Nervosa, where individuals attempt to lose weight by binge eating, followed by purging which is self-induced vomiting. Current statistics show that 8% of women have bulimia at some point in their life and 1.6 million people in the UK are affected by eating disorders. The high frequency of vomiting has severe implications for the state of enamel, and in many cases, the condition leads to complete enamel breakdown, particularly on the palatal surfaces of maxillary anterior teeth.
Tooth erosion, however, can be avoided with proper patient education by dentists. Many patients are unaware of several daily habits that can lead to erosion, but can easily be stopped. Personally, if my patients tell me that they are regular drinkers of juice or fizzy drinks, I tell them that if they have to drink them, they should always aim to drink them through a straw. This prevents the direct attack of the acid onto the anterior teeth, which reduces the overall erosion. Something I have also found is a regular occurrence with patients is fruit consumption immediately prior to brushing their teeth in the night. The issue with this is that the acid in the fruit (particularly citrus fruits and berries) leaves the enamel very soft and weak. This combined with the mechanical force of brushing leads to the wiping away of enamel which enhances the acid erosion. The way to avoid this is to wait at least an hour after eating to brush your teeth and to rinse your mouth out with water after eating.
Other than preventative advice, dentists can also use other measures to reduce erosion in more advanced cases. Fluoride varnish with 2.26% sodium fluoride can be applied to all tooth surfaces in patients who are at high risk of erosion or already have severe generalised erosion. Fluoride strengthens enamel and so provides increased protection against erosion. In even more advanced cases such as bulimia, dentists can make mouthguards which can be inserted by the patient immediately prior to vomiting to form a physical barrier between the acid and the enamel surface. The patient can also fill the mouthguard with an antacid such as milk of magnesia to counteract the acidity of the stomach contents.