Clinical Oral Investigations

https://doi.org/10.1007/s00784-020-03614-9

REVIEW

Does delayed toothbrushing after the consumption of erosive

foodstuffs or beverages decrease erosive tooth wear? A systematic
review and meta-analysis
Deng-wei Hong 1,2 & Xiu-jiao Lin 1,2 & Annette Wiegand 3 & Hao Yu 1,2,4,5

Received: 24 August 2020 / Accepted: 1 October 2020

# Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Objective Controversy exists regarding the effectiveness of delayed toothbrushing in decreasing erosive tooth wear (ETW). The
purpose of this systematic review and meta-analysis was to assess the effects of delayed toothbrushing on ETW.
Materials and methods This systematic review and meta-analysis was conducted according to the PRISMA statement and
registered in PROSPERO (CRD42020200463). PubMed, Embase, and Web of Science databases were systematically searched
with no publication year limits. Screening and data extraction were performed independently by two reviewers. In situ and
in vitro studies comparing ETW after delayed and immediate toothbrushing following an erosive attack were included. Review
Manager software 5.3 (The Cochrane Collaboration, Oxford, UK) was used for statistical analyses. Heterogeneity was assessed
with the Cochran Q test and I2 statistics.
Results Of the 565 potentially relevant studies, 26 full-text articles were assessed for eligibility. Twelve articles were included in
the systematic review, and 11 were included in the qualitative analyses. No significant difference in the ETW of human enamel
was observed between delayed and immediate toothbrushing (P = 0.13), whereas significantly less ETW of bovine enamel was
observed after delayed toothbrushing (P < 0.001). No significant difference in the ETW of bovine dentin was observed between
delayed and immediate toothbrushing (P = 0.34). Studies on human dentin were not available. Subgroup analyses revealed a
significant contribution of the use of fluoridated toothpaste to decreasing the ETW of human enamel after erosion and toothbrush
abrasion (P = 0.02).
Conclusions Bovine and human teeth behaved differently in response to erosion and toothbrush abrasion. Delayed toothbrushing
after an erosive attack was not effective at decreasing the ETW of human enamel compared to immediate toothbrushing, whereas
it was effective at decreasing the ETW of bovine enamel.
Clinical relevance Delayed toothbrushing alone after the consumption of erosive foodstuffs or beverages is not capable of
preventing erosive enamel wear.

Keywords Toothbrushing . Erosive tooth wear . Saliva . Remineralization

Electronic supplementary material The online version of this article

(https://doi.org/10.1007/s00784-020-03614-9) contains supplementary
material, which is available to authorized users.

* Hao Yu
haoyu-cn@hotmail.com
1
Fujian Key Laboratory of Oral Diseases & Fujian Provincial
Engineering Research Center of Oral Biomaterial & Stomatological
Key Laboratory of Fujian College and University, School and
Hospital of Stomatology, Fujian Medical University, Fuzhou, China
2
Department of Prosthodontics & Research Center of Dental Esthetics
and Biomechanics, Fujian Medical University, Fuzhou, China
3
Department of Preventive Dentistry, Periodontology and Cariology,
University Medical Center Göttingen, Göttingen, Germany
4
Department of Applied Prosthodontics, Graduate School of
Biomedical Sciences, Nagasaki University, Nagasaki, Japan
5
Department of Prosthodontics, School and Hospital of Stomatology,
Fujian Medical University, 246 Yangqiao Zhong Road,
Fuzhou 350000, China

Introduction
Erosive tooth wear (ETW) is defined as a chemical-
mechanical process resulting in the loss of tooth tissue that
is not caused by bacteria [1, 2]. ETW is a multifactorial con-
dition and can be caused by intrinsic (e.g., gastric reflux and
excessive vomiting) and/or extrinsic (e.g., consumption of
acidic foods and drinks and exposure to acid fumes at work)
factors [1]. Because of the increased consumption of erosive
foodstuffs or beverages [3] and the insufficient training of
clinicians to diagnose the condition in its early stages [4–7],
the prevalence of ETW is steadily increasing, particularly in
children and adolescents [8, 9]. As the process of ETW is
irreversible, preventive measures are needed to impede the
progression of ETW [10], and behavioral risk management
plays a crucial role in these measures [11].
Tooth surface demineralization and softening occurs after
an acidic attack, and the softened surface layer is more sus-
ceptible to toothbrush abrasion than the noneroded tooth sur-
face [1, 8, 12–14]. As shown in previous studies, the softened
surface layer might reharden after exposure to saliva for a
certain period [15, 16]. The rehardening potential of saliva is
related to the supersaturation of calcium, phosphate, and fluo-
ride contained in saliva [17]. Therefore, a rational approach to
increase the abrasion resistance of eroded dental hard tissues
appears to be delaying toothbrushing after an erosive attack.
According to some in vitro and in situ studies, delayed tooth-
brushing leads to lower ETW than toothbrushing immediately
after an erosive attack. Jaeggi et al. [9] reported that after an
erosive attack, toothbrushing after a 60-min exposure to saliva
caused significantly less erosive enamel wear than immediate
toothbrushing (0.19 μm vs. 0.25 μm, respectively). A study
with a similar design showed a 52% decrease in the erosive
enamel loss after a 10-min immersion in saliva and a 78%
decrease after a 30-min immersion in saliva [18]. With respect
to dentin, a previous in situ study reported a decrease in the
erosive dentin wear upon exposure to saliva for 30 to 60 min
after exposure to acidic drinks [19]. Thus, it has been recom-
mended to postpone toothbrushing for 30 to 60 min after the
consumption of erosive foodstuffs or beverages to avoid, or at
least minimize, ETW [20–22].
However, an epidemiological study [23] and a case-control
study [24] did not observe a direct relationship between de-
layed toothbrushing and the degree of ETW. Amorphous min-
eral deposition on the eroded tooth surface after exposure to
saliva may not be an ideal form of mineralization [25–27]. In
other words, a clinically significant remineralization of eroded
tooth surface might not have been achieved after immersion in
saliva. The remineralization of eroded enamel by natural sali-
va is not able to withstand the subsequent toothbrush abrasion
[28] and is removed by ultrasonication [29]. Furthermore, no
significant differences in erosive enamel wear were observed
between immediate toothbrushing and toothbrushing after
Clin Oral Invest
waiting 4 h after an acid attack [8]. Similarly, remineralization
of eroded dentin did not reduce its susceptibility to toothbrush
abrasion [15]. Therefore, the current evidence suggests
reconsidering the recommendation of delayed toothbrushing
of dental hard tissues after an erosive attack [28, 30].
Therefore, the present systematic review and meta-analysis
was conducted to compare the ETW between delayed and
immediate toothbrushing of erosively softened tooth hard tis-
sues. The null hypothesis is that no difference would be ob-
served in the ETW of enamel and dentin between immediate
and delayed toothbrushing after an erosive attack.
Materials and methods
Protocol and registration
This systematic review and meta-analysis was performed ac-
cording to the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) statement [31] and
registered in the PROSPERO database (registration number:
CRD42020200463). The present systematic review aimed to
answer the following question: does delayed toothbrushing
reduce ETW to a greater extent than immediate toothbrushing
after the consumption of erosive foodstuffs or beverages?
Search strategy
The search was conducted in the PubMed, Embase, and Web
of Science databases for published papers. Manual searches
were conducted to complement the database searches. No
publication year limit was imposed. The search terms and their
combinations used in the literature search are listed in Table 1.
The last search was performed on July 25, 2020. The PICOS
questions were defined as follows: P-population: enamel and
dentin; I-intervention: storage in natural saliva before tooth-
brushing; C-control: specimens that were not stored in natural
saliva before toothbrushing; O-outcome: an evaluation of
whether storage in natural saliva reduced the ETW; S-study
designs: in vitro, in situ, or in vivo studies.
Study selection and eligibility criteria
Initially, study identification was independently performed by
two authors (H.D. and L.X.) by analyzing the titles and ab-
stracts of published studies included in the electronic data-
bases. Any disagreements between the two authors were re-
solved by discussion and consensus. In the absence of a con-
sensus, a third reviewer (Y.H.) participated in the discussion
until a consensus decision was reached [32].
Articles were considered for inclusion in this systematic
review if all of the following criteria were satisfied: (1) studies
measured the ETW of enamel or dentin due to acid erosion
Clin Oral Invest

Table 1 Search terms and combinations used in the literature search

Database Search terms and combinations used

Medline via PubMed (((tooth erosion [MeSH] OR tooth erosion* OR dental erosion OR enamel erosion OR dentin* erosion OR erosive tooth wear
OR erosive dental wear OR erosive enamel wear OR erosive dentin* wear OR tooth wear [MeSH] OR dental wear OR
enamel wear OR dentin* wear)) AND (saliva [MeSH] OR natural saliva OR human saliva OR tooth remineralization OR
dental remineralization OR enamel remineralization OR dentin* remineralization)) AND (toothbrushing [MeSH] OR
toothbrushing OR tooth brushing OR brushing).
Web of Science and (((“tooth erosion” OR “dental erosion” OR “enamel erosion” OR “dentin* erosion” OR “erosive tooth wear” OR “erosive
Embase dental wear” OR “erosive enamel wear” OR “erosive dentin* wear” OR “tooth wear” OR “dental wear” OR “enamel wear”
OR “dentin* wear”)) AND (“saliva” OR “natural saliva” OR “human saliva” OR “tooth remineralization” OR “dental
remineralization” OR “enamel remineralization” OR “dentin* remineralization”)) AND (“toothbrushing” OR “tooth
brushing” OR “brushing”)

and toothbrush abrasion; (2) eroded enamel or dentin was
stored in saliva for a certain period; and (3) articles were pub-
lished in English. Articles meeting one or more of the follow-
ing criteria were excluded: (1) artificial saliva was used; and
(2) the article was a review, protocol, or clinical guideline.
Data extraction and collection
A protocol for data extraction was defined and evaluated by
two independent reviewers (H.D. and L.X.). The following
data were extracted from the included studies and recorded
in Excel spreadsheets (Microsoft Corporation, Redmond,
Washington, USA): authors, year of publication, sample size,
acidic solutions used for erosion, duration of storage in saliva,
erosion/abrasion cycles, study durations, number of erosion/
abrasion cycles, toothbrushing protocol, toothpaste used (e.g.,
toothpaste type and relative dentin abrasivity (RDA)/relative
enamel abrasivity (REA)), measurements of ETW, and study
design (e.g., in vitro, in vivo, or in situ).
If necessary, the standard deviations were derived or
estimated from other related information (e.g., standard
errors or confidence intervals) based on the calculations
provided in the Cochrane Handbook for Systematic
Reviews of Interventions [33].

Fig. 1 Flow diagram of study

565 potentially relevant studies 0 additional studies identified
Identification

selection according to the

PRISMA statement. PRISMA, identified from electronic databases through other sources including con-
MEDLINE via PubMed: 181 tact with researchers
Preferred Reporting Items for
Web of Science: 300
Systematic Reviews and Meta- Embase: 84
Analyses
Screening

452 studies after

removal of duplicates

426 obviously
Kappa=0.9
irrelevant studies excluded

26 full-text articles
assessed for eligibility
Eligibility

Kappa=0.9 14 records excluded

- artificial saliva was used: 7

12 studies included in the system-
atic review -bleaching: 2
Included

11 studies included in the meta-

analysis
 Clin Oral Invest

Risk of bias assessment

Lopes et al.
2020 [28]

Low
A protocol adapted from previous systematic reviews was

Y
Y

Y
N
Y
employed to examine the quality and risk of bias of the in-
cluded studies [32, 34]. The following parameters were
et al. 2019 [39]
Steiger-Ronay
assessed for each study: the sample size calculation, specimen
randomization, the specific toothbrushing method (e.g.,

Medium
manual/power toothbrushing and toothbrushing duration),
N

N
Y

N
Y
Y
clearly specified erosion and abrasion protocols (e.g.,
erosion/abrasion cycles), adequate statistical analysis, and
Tsuda et.al
2016 [38]

Medium
tests executed by a single-blinded operator.
If a specific parameter was reported, the article received a
N

N
Y

N
Y
Y
“Y,” while unreported parameters received an “N.” The levels
of the risk of bias were defined as follows: 1 or 2 “Y” items
Ferreira et al. Lussi et al.
2014 [30]

Medium
indicated a high risk of bias, 3 or 4 “Y” items indicated a
medium risk of bias, and 5 to 6 “Y” items indicated a low risk
N

Y
Y

N
Y
Y

of bias.
2013 [37]

Medium

Data analyses
Y

N
Y

Y
N
Y

The meta-analysis reported the present study was performed

Ganss et al.

using Review Manager software (Review Manager v5.3; The

2007 [14]

Cochrane Collaboration, Oxford, UK). Cochran’s Q test and

High

I2 test were employed to assess statistical heterogeneity. When

N

N
Y

N
N
Y

moderate or high heterogeneity (I2 > 50%)was observed, a

Rios et al.
2006 [36]

random-effects model was used; otherwise, a fixed-effects

Medium

model of analysis was used. Sensitivity analyses were per-

formed by excluding individual studies from the pooled
N

Y
Y

N
Y
Y

meta-analyses to evaluate the robustness of the results of the

Attin et al.
2004 [16]

meta-analyses [35]. The standardized mean difference (SMD)

High

was reported instead of the mean difference (MD) when the

N

N
Y

N
N
Y

included studies all assessed the same outcome but measured

it using various methods [33].
Hara et al.
2003 [19]

Medium

Subgroup analyses were performed to identify any poten-

tial sources of heterogeneity. The subgroup analyses included
N

Y
Y

Y
Y
Y

the following parameters: the duration of storage in saliva

(storage in natural saliva ≤30 min, 30 min < storage in natural
2001b [15]
Attin et al.

Medium

saliva ≤ 60 min, 60 min < storage in natural saliva≤120 min,

and 120 min < storage in natural saliva ≤ 240 min); the type of
N

Y
Y

N
Y
Y

study (in situ and in vitro study); and the toothpaste applied
Jaeggi et al. Attin et al.
2001a [8]

(nonfluoridated and fluoridated toothpaste). The significance

Risk of bias for the included studies

Medium

level was set to a P value < 0.05.

N

N
Y

N
Y
Y

Results
1999 [9]

Medium
N

Y
Y

Y
N
Y

Study selection
Erosive and abrasive
cycling protocol

Statistical analysis
Brushing protocol

A total of 565 studies were initially identified using the

Blinded operator
Randomization

established search strategy. One hundred thirteen studies were

calculation

Risk of bias
Sample size

duplicates and were removed. The literature search produced

Table 2

452 potentially relevant titles and abstracts. After reviewing,

26 full-text articles were selected and 12 of them met the
Table 3 Characteristics of the included studies

Authors (year) Duration of Sample Number of Study Acidic solutions Time of Toothbrushing Toothpaste used Dental ETW Study
storage in saliva size erosion/ duration used each methods hard measurement design
Clin Oral Invest

abrasion (day) erosive tissues

cycles challenge tested

Jaeggi et al. 30 min, 60 min 10 Once a day 1 Citric acid (pH = 3.5) 3 min Manual toothbrush Fluoridated toothpaste Human Indentation In situ
(1999) [9] 30 s; (Elmex®, Wybert, enamel
using their preferred Lörrach, Germany):
brushing technique RDA value: 77
REA value: 4.5
Attin et al. 10 min, 20 min, 10 Twice a day 21 Sprite Light® 90 s Electric toothbrush Fluoridated toothpaste Human Profilometer In situ
(2001a) [8] 30 min, 60 min (pH = 2.91) 42 times for 15 s; (Elmex® red, Gaba AG, enamel
1.8 ± 0.4 N Therwil, Switzerland);
RDA value: 77 ± 2 REA
value: 4.2 ± 0.3
Attin et al. 15 min, 30 min, 10 Ten times a 1 Sprite Light® 1 min Automatic brushing Fluoridated toothpaste Bovine Profilometer In vitro
(2001b) 45 min, 60 min, day (pH = 2.84) machine 100 (Gaba, Therwil, dentin
[15] 90 min, 120 min brushing strokes Switzerland); RDA
(100 strokes/min); value: 77 ± 2 REA
4N value: 4.2 ± 0.3
Hara et al. 20 min, 40 min, 20 Twice a day 3 Sprite Light® 90 s Manual toothbrush 40 Fluoridated toothpaste Bovine Profilometer In situ
(2003) [16] 60 min (pH = 2.91) brushing strokes (Colgate, Osasco, SP, dentin
Brazil) RDA value: n.a.
REA value: n.a
Attin et al. 10 min, 20 min, 11 Twice a day 21 Sprite Light® 90 s Electric toothbrush Fluoridated toothpaste Bovine Profilometer In situ
(2004) [16] 30 min, 60 min (pH = 2.91) 15 s (Elmex®, Wybert, dentin
Lörrach, Germany):
RDA value: 77 ± 2
REA value: 4.2 ± 0.3
Rios et al. 60 min 18 Four times a 7 Coca-Cola (pH: n.a.) 5 min Manual toothbrush 30 Fluoridated toothpaste Human Profilometer In situ
(2006) [36] day brushing strokes (Crest, USA): and
RDA value: n.a. bovine
REA value: n.a enamel
Ganss et al. 120 min 10 Twice a day 5 Citric acid (pH = 2.3) 20 min Electric toothbrush Nonfluoridated toothpaste Human Profilometer In situ
(2007) [14] 30 s; 2 N (GABA International enamel
AG, Münchenstein,
Switzerland):
RDA value: 77
REA value: n.a
Ferreira et al. 60 min 24 Four times a 5 Coca-Cola (pH: n.a.) 5 min Manual toothbrush Nonfluoridated toothpaste: Human Profilometer in situ
(2013) [37] day 30 s RDA value: n.a. enamel
Twice a day (after REA value: n.a
the second and last
erosive episodes)
Lussi et al. 30 min, 120 min, 10/50 Once a day 1 Orange juice 3 min Automatic brushing Fluoridated toothpaste Human Indentation In vitro
(2014) [30] 240 min (pH = 3.6) machine 50 (Elmex Kariesschutz; enamel
brushing strokes
Table 3 (continued)

Authors (year) Duration of Sample Number of Study Acidic solutions Time of Toothbrushing Toothpaste used Dental ETW Study
storage in saliva size erosion/ duration used each methods hard measurement design
abrasion (day) erosive tissues
cycles challenge tested

(120 strokes/min); GABA, Basel,

1.5 N Switzerland):
RDA value: n.a.
REA value: n.a
Tsuda et al. 3 min, 30 min, 10 Twice a day 3 Coca-Cola (pH: 2.3) 90 s Automatic brushing Fluoridated toothpaste Bovine White light In situ
(2016) [38] 60 min machine 30 (CLINICA, Lion, enamel interferom-
brushing strokes Tokyo, Japan): eter
250 g RDA value: n.a.
REA value: n.a
Steiger-Ronay 30 min, 60 min, 20 Once a day 1 Citric acid (pH = 3.6) 2 min Automatic brushing Fluoridated toothpaste Bovine Profilometer In vitro
et al. (2019) 120 min machine 100 (Elmex Kariesschutz®, enamel and
[39] brushing strokes GABA, Basel, indentation
(120 strokes per Switzerland):
min); 2 N RDA value: 65 ± 3
REA value: n.a
Lopes et al. 30 min, 60 min, 10 Four times a 5 Citric acid (pH = 2.6) 5 min Electric toothbrush Fluoridated toothpaste Human Profilometer In vitro
(2020) [28] 90 min, day 15 s; 2 N (Colgate Máxima enamel
120 min, Twice a day (after the Proteção,
240 min first and last erosive Colgate-Palmolive,
episodes) Osasco, SP, Brazil):
RDA value: n.a.
REA value: n.a
Clin Oral Invest
Clin Oral Invest
inclusion criteria. A detailed flow chart of the study retrieval
process is presented in Fig. 1.
Risk of bias
Two studies presented a high risk of bias [14, 16], while the
remaining studies presented a medium risk of bias [8, 9, 15,
19, 28, 30, 36–39]. All 12 studies provided a clearly specified
erosive and abrasive cycling protocol and appropriate statisti-
cal analysis. A description of the specific toothbrushing meth-
od was considered missing in six studies: one study [36] did
not report the brushing force, two studies did not report the
number of brushing strokes [14, 28], and three studies [9, 16,
37] did not report either the brushing force or the number of
brushing strokes. Details are illustrated in Table 2. The risk of
bias for the excluded studies [40–53] at the eligibility screen-
ing step is illustrated in Supplementary Table 1.
Descriptions of the included studies
The eligible articles were published between 1999 and 2020.
Eight in situ studies were included, of which four studies
investigated human enamel [8, 9, 14, 37], one investigated
bovine enamel [38], two investigated bovine dentin [16, 19],
and one investigated both human and bovine enamel [36].
Four in vitro studies were included, of which two studies
investigated human enamel [28, 30], one investigated bovine
enamel [39], and one investigated bovine dentin [15]. Among
all eligible studies, no study analyzed human dentin.
Regarding the studies on human enamel [8, 9, 14, 28, 30,
36, 37], the pH values of the acidic solution ranged from 2.3 to
3.6, the study duration ranged from 1 to 21 days, the number
of daily erosion/abrasion cycles ranged from 1 to 4 cycles, and
the time of each erosive challenge ranged from 90 s to 20 min.
Regarding the studies on bovine enamel [36, 38, 39], the pH
Fig. 2 Forest plot summarizing ETW of eroded human enamel after immediate toothbrushing and delayed toothbrushing. CI, confidence interval; SD,
standard deviation. DT, delayed toothbrushing; IT, immediate toothbrushing
values of the acidic solution ranged from 2.3 to 3.6, the study
duration ranged from 1 to 7 days, the number of daily erosion/
abrasion cycles ranged from 1 to 4 cycles, and the time of each
erosive challenge ranged from 90 s to 5 min. Regarding the
studies on bovine dentin [15, 16, 19], the pH values of the
acidic solution ranged from 2.91 to 2.84. The study duration
ranged from 1 to 21 days, the number of daily erosion/
abrasion cycles ranged from 1 to 10 cycles, and the time of
each erosive challenge ranged from 60 to 90 s. The
profilometric analyses and the indentation method were used
to assess the ETW. For the profilometric analyses [8, 14–16,
19, 28, 36–39], step heights between reference and abraded
surface areas were obtained. For the indentation methods [9,
30, 39], surface loss was calculated by measuring the change
in depth of the same Knoop diamond indentation before and
after abrasion. The selected characteristics of the included
studies are shown in Table 3.
Meta-analysis and quality of evidence
Of the 12 studies included in the systematic review, one
study [36] did not provide the standard deviation values
required to perform the meta-analysis, and they were
unable to be derived or estimated from other related
information; therefore, this study was excluded from
the meta-analysis. The treatment group of one study
[14] was not included in the meta-analyses because the
treatment group was not only treated with fluoride
toothpaste but also fluoride solution and fluoride gel.
The sensitivity analysis did not reveal significant chang-
es in heterogeneity and the results of the meta-analysis
after the exclusion of any study, indicating that the re-
sults were robust.
Three global meta-analyses were performed considering
the type of tooth hard tissues (human enamel, bovine enamel,
Clin Oral Invest
 Clin Oral Invest
ƒFig. 3 Forest plot summarizing the subgroup analyses of the
effectiveness of delayed toothbrushing at decreasing the ETW of eroded
human enamel. a, subgroup: duration of storage in saliva; b, subgroup:
type of study design; c, subgroup: the toothpaste used. CI, confidence
interval; SD, standard deviation; DT, delayed toothbrushing; IT,
immediate toothbrushing
and bovine dentin). Regarding the human enamel, the global
analysis did not reveal a significant difference in ETW be-
tween the immediate and delayed toothbrushing groups (P =
0.11; SMD − 0.16; 95% confidence interval [CI] − 0.35 to
0.03). In the subgroup analyses, no significant differences
were found between groups stratified by the duration of stor-
age in saliva and the type of study (all P > 0.05). A significant
difference in ETW was found between the fluoridated tooth-
paste and nonfluoridated toothpaste subgroups (P = 0.05):
when eroded human enamel specimens were brushed with
fluoridated toothpaste, a statistically significantly lower
ETW was found in the delayed toothbrushing group than in
the immediate toothbrushing group (P = 0.02), while no sig-
nificant differences were found in the specimens brushed with
nonfluoridated toothpastes (P = 0.39). Details are provided in
Figs. 2 and 3.
Regarding the bovine enamel, the global analysis
showed a significant difference in ETW between imme-
diate and delayed toothbrushing, favoring delayed tooth-
brushing after the consumption of erosive foodstuffs or
beverages (P < 0.00001; SMD − 1.48; 95% CI − 2.14 to
− 0.82). In the subgroup analyses, significant differences
were found between groups stratified by the type of
study (P = 0.0001), while no significant difference was
found for the groups stratified by the duration of stor-
age in saliva (P = 0.30). When the eroded bovine enam-
el specimens were tested in situ, a significantly lower
SMD was found than specimens tested in vitro (− 3.65
vs. − 0.79). Details are illustrated in Figs. 4 and 5.
Regarding the bovine dentin, the global analysis did not
reveal significant differences in ETW between immediate
and delayed toothbrushing (P = 0.34; SMD − 0.12; 95% CI
− 0.36 to 0.12). In the subgroup analyses, no significant
Fig. 4 Forest plot summarizing the ETW of eroded bovine enamel after immediate toothbrushing and delayed toothbrushing. CI, confidence interval;
SD, standard deviation; DT, delayed toothbrushing; IT, immediate toothbrushing
differences were found between groups stratified by the dura-
tion of storage in saliva (P = 0.65) and the type of study (P =
0.49). Details are provided in Figs. 6 and 7.
Discussion
Establishing good oral hygiene is valuable for the control of
dental diseases [54, 55]. The optimal interval between a meal
and toothbrushing has been an issue of concern in the litera-
ture [18, 56]. Regarding ETW, delayed toothbrushing of den-
tal hard tissues after the consumption of erosive foodstuffs or
beverages has been recommended based on the potential
rehardening effects of saliva. However, no consensus has been
reached regarding the effects of saliva on eroded dental hard
tissues. Therefore, the present study comprehensively
reviewed the effects of delayed toothbrushing of dental hard
tissue on ETW to provide evidence-based recommendations.
Based on the results of the meta-analysis, the null hypothesis
that no difference would be observed in ETW between de-
layed toothbrushing and immediate toothbrushing was accept-
ed for human enamel and bovine dentin but was rejected for
bovine enamel.
According to the meta-analysis, delayed toothbrushing of
eroded human enamel was not effective at decreasing ETW,
regardless of the duration of storage in natural saliva. The
remineralization produced by saliva is not only small but also
a slow process, occurring only on the surface of the lesions
[57]. Moreover, even after 240 min of storage in saliva [28],
the softened enamel surface layer was still mechanically
fragile and provided insufficient protection against tooth-
brush abrasion [36, 58, 59]. A scanning electron microscopy
(SEM) observation revealed that the persistence of etching
patterns in etched enamel after 90 days intraorally,
supporting the hypothesis that salivary remineralization only
exerted a minor effect on erosively softened human enamel
[60]. However, the subgroup analysis revealed a significant
difference between the human enamel brushed with fluori-
dated and nonfluoridated toothpastes. ETW was

significantly decreased when fluoride-containing tooth-
pastes were used. It can be speculated that the toothpaste
abrasivity is partially counteracted by the presence of fluo-
ride, resulting in the partial removal of mineral precipitation
instead of total removal. This hypothesis was corroborated
by a previous study in which fluoridated toothpastes caused
less abrasive wear than nonfluoridated toothpastes [61]. In
addition, the acquired enamel pellicle serves as a diffusion
barrier to ionic conductivity on the enamel surface and con-
tributes to the formation and stabilization of CaF2 [62–64].
Fig. 5 Forest plot summarizing the subgroup analyses of the
effectiveness of delayed toothbrushing at decreasing the ETW of eroded
bovine enamel. a, subgroup: duration of storage in saliva; b, subgroup:
Clin Oral Invest
Because fluoridated toothpastes accounted for over 90% of
the market in industrialized nations [65], future studies in this
field should use fluoridated toothpastes to provide clinically
relevant evidence. Notably, the abrasivity of toothpaste is
considered an important modulator of the development of
tooth wear [61]. However, the softened surface layer of ero-
sive enamel was easily removed in several studies, regardless
of the abrasive type [37]. Future studies are needed to explore
the potential correlation between the abrasivity of toothpaste
and ETW.
type of study design. CI, confidence interval; SD, standard deviation; DT,
delayed toothbrushing; IT, immediate toothbrushing
Clin Oral Invest
In contrast to human enamel, the meta-analysis showed that
delayed toothbrushing of eroded bovine enamel was effective
at decreasing ETW, even when the storage time was less than
30 min. This might be attributed to the differences in physio-
chemical properties and morphology between the bovine and
human enamel [66, 67]. Eroded bovine enamel was found to
have larger crystal and a higher demineralized porosity com-
pared to eroded human enamel [68, 69]. Those differences
may influence the pattern of mineral deposition and allow
fluoride ions to penetrate into deeper areas. However, these
hypotheses need to be clarified in future studies.
Regarding the bovine dentin, the meta-analysis showed
that delayed toothbrushing was not effective at decreasing
ETW, regardless of the duration of storage in saliva. The
remineralization of dentin is generally difficult to achieve
[70, 71] because of the limited amounts of residual mineral
crystals available for apatite nucleation and growth [72] and
the degradation of collagen fibrils [70]. Dentin, which con-
tains 30% volume organic matrix (mainly type I collagen) as a
scaffold for apatite deposition, is different from enamel [73].
The ideal form of mineralization on the dentin surface is amor-
phous minerals deposited on the collagenous matrix and in-
corporated into the collagen fibrils [74]. After demineraliza-
tion, however, the inactive dentin-derived matrix metallopro-
teinases are exposed and activated in acidic environments, and
these active enzymes are responsible for the disintegration of
the exposed collagen fibrils [75, 76]. However, further studies
examining human dentin are necessary to confirm the effect of
delayed toothbrushing on ETW.
The subgroup analyses did not reveal a significant differ-
ence between in situ and in vitro findings for human enamel
and bovine dentin. A possible explanation is that human sali-
va, collected by spitting or drooling, was used in all in vitro
studies included in the meta-analysis. Although changes in the
chemical composition of collected saliva in vitro have been
observed compared to the fresh saliva in situ [77], the collect-
ed saliva is still supersaturated with respect to tooth minerals
Fig. 6 Forest plot summarizing the ETW of eroded bovine dentin after immediate toothbrushing and delayed toothbrushing. CI, confidence interval; SD,
standard deviation; DT, delayed toothbrushing; IT, immediate toothbrushing
[78], which may eliminate the differences between in situ and
in vitro studies. Interestingly, a significant difference was
found in the ETW of bovine enamel between in situ and
in vitro studies. More specifically, the effects of delayed tooth-
brushing on the ETW of bovine dentin were greater in the in
situ studies than in the in vitro studies. The explanation for this
phenomenon remains unclear. However, this finding was
based on only 1 in situ study and 1 in vitro study.
Based on the present findings, the current evidence for
delaying toothbrushing to reduce ETW is insufficient, and the
recommendation to postpone toothbrushing after the consump-
tion of erosive foodstuffs or beverages is not supported by this
meta-analysis. The sensitivity analyses confirmed the robustness
of these findings. Funnel plots were not conducted because the
number of studies included in each meta-analysis was less than
ten [79]. No review or meta-analysis can be performed on human
dentin or other types of measurements (e.g., surface microhard-
ness measurements) due to the limited number of studies, which
is considered a limitation. All included studies were classified as
having a high or medium risk of bias due to the lack of informa-
tion on the sample size calculation, teeth randomization, and
blinding of the operator, which should be carefully considered
in future studies. Moreover, since the present findings were based
on in vitro and in situ studies, the results must be interpreted with
caution. Further randomized controlled clinical trials are neces-
sary to confirm the present findings.
Conclusion
Bovine and human teeth behaved differently in response to
erosion and toothbrush abrasion. Delayed toothbrushing after
an erosive attack was not effective at decreasing the ETW of
human enamel and bovine dentin compared to immediate
toothbrushing, whereas it was effective at decreasing the
ETW of bovine enamel.
 Clin Oral Invest

Fig. 7 Forest plot summarizing the subgroup analyses of the type of study design. CI, confidence interval; SD, standard deviation; DT,
effectiveness of delayed toothbrushing at decreasing the ETW of eroded delayed toothbrushing; IT, immediate toothbrushing
bovine dentin. a, subgroup: duration of storage in saliva; b, subgroup:

Funding This study was partially supported by the Guiding Project for Compliance with ethical standards
Science and Technology of Fujian Province (2018Y0029), and the Joint
Fund for Scientific and Technological Innovation of Fujian Province
Conflict of interest The authors declare that they have no conflict of
(2019Y9030).
interest.
Clin Oral Invest
Ethical approval This article does not contain any studies with human
participants or animals performed by any of the authors.
Informed consent For this type of study, informed consent is not
required.
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