Chemical Erosion

Small lifestyle changes can reduce the damage from an acid attack
BY JAMIE COLLINS, RDH, CDA

A day in dental hygiene presents a melting pot of oral and anterior teeth. Patients may not be aware of the erosion process
systemic issues among the patients we see. No two days or and may have no symptoms, especially early in the process. If
two mouths are ever the same. Even the patients we’ve seen the erosion is significant, patients may complain of increased
for years may present with different signs or symptoms at sensitivity. When clinicians see evidence of erosion, we should
their next dental visit. With the daily focus on decay and be asking our patients the right questions in order to investigate
periodontal disease, how often do you identify and counsel
on other conditions? Think back to the last week of seeing
patients in your hygiene chair. How many did you see that
displayed evidence of acid erosion?
Acid erosion in the oral cavity is a rather common
condition and seems to be becoming more prevalent.
Fifty percent of dental professionals report an increase
in erosion over the last five years. Erosion is caused by
prolonged exposure of the tooth surface to extrinsic
or intrinsic acids. Erosion is classified as loss of hard
tooth structure, enamel, or dentin, by a nonbacterial
acidic source. The structure of the tooth is exposed to
a consistent acidic source and is not able to reminer-
alize effectively, thus breaking down the hydroxyap-
atite within the enamel matrix. The tooth softens
and becomes more susceptible to other forms of
wear, such as abrasion and attrition.
Clinically, acid erosion appears as cupping on the
occlusal surface. When I see this, I describe it as a
smooth “pothole.” On the facial or lingual surfaces of the
posterior teeth, erosion appears as a smooth or flat surface,
or the enamel layer is missing or thin, often at the cervical
junction. In any area of chemical erosion, we may clinically
see the yellowish hue of the underlying dentin layer
since the enamel is thinner.
Acid erosion is often present on
the cusp tips of posterior
teeth or the lingual sur-
face of maxillary

58 AUGUST 2016 | RDHMAG.COM

1608rdh_58 58 8/4/16 2:02 PM


the cause and to plan prevention so
there’s no further damage.
DIETARY CONCERNS
Today’s American diet is much more
acidic than in previous decades.
This partially explains the increas-
ing erosion prevalence in the US
population. Soft drinks, juices, wine,
energy drinks, and sports drinks are
common staples of the American
diet. Most of these drinks have a pH
level less than 4.0, much lower than
the pH level of 5.5 where enamel
demineralization begins, or 6.5
where dentin starts to break down.
For many people, the drive for
caffeine and energy develops into a
habit of drinking soda, coffee, or
energy drinks throughout the day.
They often sip on the drinks for
hours at a time. The constant bath-
ing of the acidic drinks keeps the
pH of the oral cavity lower than
what is ideal and thus not only in-
creases the incidence of decay, but
also the risk of acid erosion on the
teeth. Many soft drinks contain one
or more of the commonly added
acids used to create taste and in-
hibit bacterial growth—citric acid,
phosphoric acid, and carbonic acid.
The acids used in conjunction with
the sugars of these drinks can lead
to decay in susceptible areas
where erosion has oc-
curred because
the enamel
1608rdh_59 59
is weakened. Some evidence sug-
gests that phosphoric acid may also
be linked to lower bone density and
an increased risk of kidney stones.
Acid erosion is not only evident
in adults; many children are affected
as well. Fruit juices are a common
culprit for erosion in the primary
dentition of children, with a pH
generally in the range of 3 to 4.
When combined with bruxism,
which children often do as the den-
tition changes, obvious clinical signs
of chemical erosion can be ob-
served. Children often present with
smooth dimpling on the occlusal
surfaces of the molars, and some-
times the lingual of the anterior
teeth are also affected. The primary
dentition is not as strong as the
permanent dentition and can be
sensitive and wear easily. We often
clinically see the yellow hue of the
underlying dentinal layer in the ar-
eas of wear and erosion.
The pH of energy drinks, which
have become a source of quick en-
ergy, can range from 2.53 to 3.49.
I’ve had patients admit to drinking
three or more of these drinks a day
and wonder why they have decay
and acid erosion accompanied by
sensitivity. Most people are not
aware of the dental implications of
their habit, and many think a cavity
will be the worst of their problems.
I talked with my husband, who
works in a corporate office setting,
and he listed several coworkers who
are never without an energy drink
or soda within arm’s reach
throughout
the day. He said one comes to work
with a cooler of four to five energy
drinks each day. The hygienist in
me quietly screams when I hear this,
and I feel the need to do some nu-
tritional counseling for these
people!
Remember,
prevention is
always the
best medicine.
Take time to
educate your
patients about
the causes and
effects of acid
erosion.
I admit to needing my caffeine
boost each day, and I’m pretty sure
my patients like me better because
of it. Discussing these habits with
patients is often similar to discuss-
ing tobacco use. Many people are
very reluctant to change habits and
might be afraid you’re asking them
to give up a habit they feel gets them
through the day. I never ask my pa-
tients to give up their caffeine habit,
but I instead ask them to change
how they consume it. If people sip
acidic drinks slowly, they expose
their teeth to acid attack for longer
periods of time. I would rather see
them drink it down and be done
with it, and then drink water after-
ward to allow the saliva to buffer
the acid and return the oral cavity
to a normal pH level. The salivary
glands naturally increase flow,
and bicarbonates and urea in
saliva clear acid from the oral
cavity and return the pH to
a normal range if given time
between exposures.
Drinks are not the only
cause of chemical erosion. The
CHEMICAL EROSION
foods we eat play a part as well.
We’ve become a society of conve-
nience, and with the ease of pro-
cessed foods and frequent snacking,
the risk of chemical erosion has
increased. Grazing throughout the
day, even on healthy alternatives
such as fruits and berries, puts the
teeth under acid attack.
ACID REFLUX
Diet is not always to blame for
chemical erosion—it may be the
result of an intrinsic factor. Gastro-
esophageal reflux disease (GERD)
is a common cause of chemical
erosion of the teeth. The acid of the
stomach and related fumes enter
the oral cavity and can be highly
acidic and erosive. The hydrochloric
acid produced in the stomach has
a pH of 1.0 to 3.0. GERD can develop
slowly and continue for years before
a patient seeks medical help. It often
occurs when lying flat at night sleep-
ing, and people often are not aware
it’s happening until they have severe
discomfort.
At least once a month my office
sends a patient to his or her medical
doctor for a GERD evaluation due
to evidence of chemical erosion
along the posterior teeth, and ex-
trinsic sources of diet or habits are
not indicated as a cause. When
these patients return to the office
months later, many say they did not
realize the symptoms were present,
but have since resolved the issue
with medication.
We all learned about the risk of
chemical erosion due to bulimia,
which involves vomiting multiple
times daily over a prolonged period
of time. The incidence of chemical
erosion is usually severe and wide-
spread, and portions of the teeth
may be missing. The topic of bulimia
is a delicate one and should be
broached with caution and compas-
sion. Frequently patients are not
willing to admit their problem and
RDHMAG.COM | AUGUST 2016 59
8/4/16 2:02 PM
 Take a walk. CHEMICAL EROSION

7/13 ñ Jim Foran Golf Event, Minnesota gaining control of it may require professional help.
7/16 ñ Charity Golf Event, Michigan The widespread use of medications can also contribute to the increased
8/07 ñ Birmingham, Michigan incidence of chemical erosion. Medications used to treat health conditions
8/13 ñ Omaha, Nebraska such as depression can slow the salivary flow and cause xerostomia. Without
adequate saliva to wash away and buffer the acidic exposures of the oral
9/18 ñ David Nasto Event, New Jersey
cavity, the risk of erosion increases along with the risk of decay. Acidic
9/24 ñ Wahpeton, North Dakota erosion is also associated with recreational drug use. Look for smooth
10/01 ñ Brooklyn, New York exposure and cupped surfaces along the gingival margins and occlusal
10/01 ñ Twin Cities, Minnesota surfaces of the posterior teeth. Systemic health conditions such as Sjogren’s
10/01 ñ Kirkland, Washington syndrome affect the function of the salivary glands and cause xerostomia.
10/02 ñ Boston, Massachusetts Asking patients right questions can help you understand the reasons behind
chemical erosion and decide the causes, whether habits, xerostomia, GERD,
10/08 ñ Baton Rouge, Louisiana
or a combination.
10/08 ñ Pewaukee, Wisconsin Treating chemical erosion involves prevention of further damage as well
10/08 ñ Lehigh Valley, Pennsylvania as treatment of existing eroded areas. The first step is to identify the cause
10/08 ñ Houston, Texas of the chemical erosion. The easiest way to start treatment is with diet and
10/22 ñ Orange County, California better habits. If the patient consistently consumes acidic drinks or foods,
nutritional counseling may be helpful. Having a patient keep a log of food

Find an
and drink over a few days may shed light on their habits and frequency.
Small changes can make a big difference in the dental erosion process.
When symptoms of GERD are present, refer the patient to a physician

Answer.
Every year at each of OCFís many walk/run
events around the country, hundreds of
individuals pay to participate in an effort to

        
       
 
 
more effective treatments and eventually a
cure.
Event funds also support patients and provide
information that may prevent others from having
this disease touch their lives. Thousands of
walkers each year are in turn supported by
donations to their personal effort made by
family, friends, and co-workers; multiplying their
individual impact many fold.
Every walk you take with OCF
brings us a step closer to a cure.
for evaluation. Untreated GERD is erosive to the esophagus and teeth, and
gastric juices can affect overall health and increase the risk of esophageal
cancer if left untreated.
No matter the cause of chemical erosion, treatment options are the
same. Use of high fluoride treatments both in office and at home are effective
in protecting the eroded surfaces and can increase acid resistance. Encourage
patients to use a straw when drinking acidic beverages to limit the contact
with tooth structure. In addition, counsel patients on the frequency of acid
exposure and recommend limiting the time teeth are exposed to an acidic
episode.
In instances where areas of chemical erosion, such as concavities, are
significant, a small filling to replace the lost tooth structure may be indicated.
In severe cases of chemical erosion, restorations such as crowns may be
necessary to repair the damaged structures. When teeth are exposed to
acid, they are more susceptible to abrasion, such as from a stiff toothbrush
or highly abrasive toothpaste. A mild toothpaste should be recommended,
and brushing should be delayed until the saliva has had a chance to buffer
the pH level, which is sometimes as long as 30 minutes after acid
exposure.
Remember, prevention is always the best medicine. Take time to educate
your patients about the causes and effects of acid erosion. RDH
Jamie Collins, RDH, CDA, resides in Idaho with her husband, Cory, and their four
children. She currently works as a full-time hygienist as well as an educator at the
College of Western Idaho. In addition, she acts as a content expert and contributor in
multiple upcoming textbooks. She can be contacted at jamiecollins.rdh@gmail.com.

REFERENCES
1. http://rdhmag.com/etc/medialib/new-lib/rdh/site-images/volume-31/is-
sue-8/1108RDH075-085.pdf
2. http://www.dental-professional.com/Conditions_AcidErosion.aspx
3. http://www.livestrong.com/article/518257-about-acid-in-carbonated-drinks/
4. http://www.healthline.com/health/acid-foods-to-avoid#Overacidity2

www.oralcancer.org ï 949-723-4400
info@oralcancerfoundation.org Circle 25 on card

1608rdh_60 60 8/4/16 2:02 PM

Copyright of RDH is the property of PennWell Corporation and its content may not be copied
or emailed to multiple sites or posted to a listserv without the copyright holder's express
written permission. However, users may print, download, or email articles for individual use.