A new look at erosive tooth wear

in elderly people
David Bartlett, BDS, PhD, FDS RCS

he importance of acids in the etiology of tooth

T 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 compro-
mise the longevity of the teeth. Approximately 7 percent
of subjects in a 1996 study had exposure of secondary
ABSTRACT
Background. The author
describes the clinical appear-
ance of and the outcomes
associated with erosive tooth
✷
J
A D A

®
✷

N
CON
dentin and the pulp that justified operative intervention.1

IO
wear, particularly that in

T
T

A
older people. N

CLASSIFICATION OF TOOTH WEAR
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 interpreta-
tion 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 grad-
ually 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
The role of abfraction in tooth wear remains controver-
sial. 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 crit-
ical 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
I
C
U
A ING EDU 3
Types of Studies RT
Reviewed. The author ICLE
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 com-
pared 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 pro-
long 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 wear.
JADA 2007;138(9 supplement):21S-25S.
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@kcl.ac.uk”.
Address reprint requests to Dr. Bartlett.

JADA, Vol. 138 http://jada.ada.org September 2007 21S

Copyright ©2007 American Dental Association. All rights reserved.

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.
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.
understood. A laboratory investigation predicted
that it would take 2,500 years of using a tooth-
brush 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 pro-
duces 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 com-
bined 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 neu-
tralize 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
22S JADA, Vol. 138 http://jada.ada.org September 2007
Copyright ©2007 American Dental Association. All rights reserved.
BOX
Common dietary acids associated
with acid erosion.*
HIGH EROSIVE POTENTIAL (EITHER FRUIT OR FRUIT
JUICES)
Citrus fruits such as lemons, grapefruits and
oranges
Apples
Cranberries
Grapes
MEDIUM EROSIVE POTENTIAL
Colas
Vinegar
White and red wine
LOW EROSIVE POTENTIAL
Beer
Carbonated water
* Source: Bartlett.12
dental erosion10 and may occur in patients who
have eating disorders, have alcoholism or experi-
ence regurgitation of gastric juice. Eating disor-
ders 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 rela-
tively 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. Conse-
quently, complex prosthodontic intervention
often is required.
PREVALENCE
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
ABBREVIATION KEY. GERD: Gastroesophageal
reflux disease.
 A B
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.
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 patho-
logical 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 com-
plex 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 complica-
tion is that their tolerance for complex restorative
JADA, Vol. 138 http://jada.ada.org
Copyright ©2007 American Dental Association. All rights reserved.
care diminishes and their ability to maintain oral
health can be compromised, particularly as a
result of reduced saliva output.
RESTORATIVE DECISION MAKING
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 rea-
sonable 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 sur-
vive the patient’s lifetime and whether the com-
plexity 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 sim-
pler, more pragmatic plan may be for the dentist
to monitor the patient’s tooth wear and provide
pain relief and endodontic treatment if necessary
September 2007 23S
but not restore the structure or appearance of the
teeth with complex prosthodontic restorations.
PREVENTION
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 sug-
gest that the erosive process is active.6 The ratio-
nale behind this is that persistent acid exposure
removes the outer layer of enamel or dentin, cre-
ating a stain-free surface. The presence of stains
indicates that the wear process is inactive, as suf-
ficient time has passed to allow dietary stains to
be taken up onto the tooth surface. Another clin-
ical 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 meal-
times, 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 expo-
sure and the length of time that the acids are pre-
sent 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
24S JADA, Vol. 138 http://jada.ada.org September 2007
Copyright ©2007 American Dental Association. All rights reserved.
who do not have tooth wear, the timing of tooth-
brushing 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 recom-
mend 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 protec-
tion.27 In this clinical study, researchers applied
dentin-bonding agent to alternate teeth of sub-
jects 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 pro-
tected 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
CONCLUSIONS
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. ■
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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