magnified through the use of dental loupes.

The disappearance
or loss of definition of the scratch over a period of 2–4
weeks suggests that the problem is active. Make a high quality
impression immediately after the scratch and compare it with
further consecutive impressions obtained 1–4 weeks later. View
the scratch in the impression itself, under magnification. This
has the advantage of providing a permanent record.
The scratch test has another important advantage because
it can help to determine the level of activity after preventive
measures have been undertaken with the patient. That is, requantification
of activity at recall visits eliminates guesswork.
This technique can also be used to determine activity with other
mechanisms, such as abrasion and, in particular, attrition.
Other approaches may use wear indexes on a longitudinal
basis. One example is the ‘BEWE’ index, Basic Erosive Wear
Examination, which gives a summative score of the worst surface,
on the worst tooth, in each sextant of the mouth. Generally,
the level of activity should be determined over a reasonable
period of time, using serial impressions, unless it is so active that
it is very obvious.
Specific contributory factors
The effect of acid on dental tissues is determined by many variables,
including the type of acid, the strength of the acid (pH
and titratable values), the amount of acid consumed, frequency
of exposure, the time the acid is consumed and subsequent oral
clearance. Other variables that also affect the final outcome, but
can be considered as protective factors, include previous fluoride
exposure, the degree of enamel maturity, the presence of
biofilm, and the quality and quantity of saliva.
It must be remembered that some acids (e.g. citric), apart
from the damaging effect resulting from the H+ ions, have a
chelating effect where Ca++ is leached out from apatite, thereby
adding to the demineralizing effects. Similarly, although pH is
the measure of H+ ions in concentration, and is used as a measure
of the potential to cause dissolution, the titratable values
of acids are at times more important [1]. Titratable values are
an indication of the number of H+ ion available to react. This
means that two acids may have the same pH, but the one with
the higher titratable value will be potentially more damaging.
Thus, acids from grapefruit and pineapple juices are more damaging
than cola drinks even though they have a lower pH.
Careful patient questioning and assessment are required to
identify contributing erosive factors that are specific for that
patient. Identifying specific drinks consumed regularly, the
frequency of consumption, medical conditions (e.g. bulimia,
Sjogren’s syndrome, etc.), medications (e.g. asthma puffers) and
poly‐pharmacy (i.e. causing hypo‐salivation), balanced against
the protective factors mentioned above, will collectively give an
indication of risk associated with that patient. This will, in turn,
influence the management of the problem.
The variability created by all these possible confounding
factors is so great that it is difficult to determine the possible
multiple levels of risk. Placing individuals in ‘low risk’ or ‘high
risk’ categories, albeit still subjective, is an acceptable technique.
Source of acid from corrosion patterns
Identifying the source of an acid (i.e. intrinsic or extrinsic) will
direct the clinician towards identifying the aetiological agents
and thus help target the management.
The pattern of corrosion that occurs may help to identify the
source of the acid, but considerable variation is possible. The
direction of acid movement within the mouth, the variations in
saliva clearance, and even the individual pattern of swallowing
may have an effect. There are specific patterns that may identify
the source of an acid, but over time, the patterns appear to
merge, making it difficult to identify the source (Figure 4.1).
Generally, intrinsic acids affect the palatal aspects of the
upper molars. Partial regurgitation of stomach contents, or
reflux, affects the palatal of the upper third molars more than
the second molars, with the first molars affected least. However,
vomiting will lead to a broader range of effects, where the palatal
surfaces of all the upper teeth can be affected. Over time, remnants
of vomitus flowing under gravity to the lower dentition
may affect other tooth surfaces, particularly the occusal surfaces
of the lower teeth. In cases of rumination, there is often a more
severe effect on upper and lower occlusal surfaces due to mastication
of the acidic remnants.
Extrinsic acids, in the form of liquids, generally produce a
different pattern. Liquids affect occlusal surfaces of the lower
teeth more than upper occlusal surfaces due to gravity. This is
a common ‘tell‐tale’ pattern that should direct the clinician to
questioning the patient about acidic drinks. Acidic drinks may
also affect the palatal aspects of the upper teeth, particularly
the upper anteriors. This relates to how liquids are distributed
around the mouth during swallowing. Unfortunately, this

a protective cover of biofilm will develop. If fluorides and/

or CPP‐ACP creams are then applied to the biofilm, the erosion
problem can be significantly reduced or even eliminated. The
remineralizing procedures should be continued after the tasting
and plaque removal carried out a number of hours later. In these
circumstances the biofilm acts as a physical barrier, and the remineralizing
products enhance supersaturated conditions within
the biofilm. Thus, a ‘closed’ system will prevent net mineral loss.
Similarly, a person who suffers from reflux while asleep can
be at risk of developing erosion because of the presence of the
acid combined with the reduced salivary flow. Apart from brushing
with a toothpaste containing a metal‐ion fluoride, for example,
stannous fluoride, the logical approach would be to advise
the patient to brush after their evening dinner and then not to
eat anything until the next day. The patient should also apply a
remineralizing product, such as CPP‐ACP creams, before bedtime.
This will allow both pellicle and biofilm build‐up between
dinner and bed‐time. At night, the combination of biofilm and
CPP‐ACP will provide a physical barrier as well as supersaturated
conditions at the time of the acid attack. The ways to use a
healthy biofilm by ‘stealth’ in prevention of erosion needs further
investigation. Simply telling a patient not to brush their teeth
could have severe negative effects on periodontal health, in particular,
‘undoing’ very quickly many years of patient advice on
oral hygiene. It is more logical to attempt to reduce the frequency
of contact with acid than it is to limit episodes of toothbrushing.
Finally, patients with evidence of intrinsic corrosion (e.g.
reflux with associated ‘heartburn’, or self‐confessed bulimics)
require referral to appropriate medical specialties to help eliminate
the cause.
Restorative approach to corrosion (erosion)
Opinions vary as to the management approach to corrosive
cases and clinical studies are lacking. As a basic principle, if
there is active corrosion that remains uncontrolled, any form
of treatment will fail. A simple approach using basic restorative
techniques may still be advocated for aesthetic reasons, provided
the patient is aware that on‐going reparative work will be
required. Complex and expensive work should be avoided, at
least until the problem is solved.
Where the preventive management is successful and the corrosion
activity stops, the clinician must remember that ‘relapse’
is still a possibility and regular monitoring of the patient, over a
reasonable period of time, is essential. Simple restorative work
should take precedence, with future complex