Acids of intrinsic and extrinsic origin are thought to be the main etiologic factors for dental erosion. There is evidence that acidic foodstuffs and beverages play a role in the development of erosion. However, the pH of a dietary substance alone is not predictive of its potential to cause erosion as other factors modify the erosive process. These factors are chemical (pKa values, adhesion and chelating properties, calcium, phosphate and fluoride content), behavioural (eating and drinking habits, life style, excessive consumption of acids) and biological (flow rate, buffering capacity, composition of saliva, pellicle formation, tooth composition, dental and soft tissue anatomy). The interplay between erosion and abrasion (specially oral hygiene practices) may be the main driver leading to the clinical manifestation of this disorder. Recommendations for patients at risk for dental erosion such as reducing acid exposure by reducing the frequency and contact of acids will be discussed.

The Role of Diet in the Aetiology of Dental Erosion

Dentin organic matrix, with type I collagen as the main component, is exposed after demineralization in dentinal caries, erosion or acidic conditioning during adhesive composite restorative treatment. This exposed matrix is prone to slow hydrolytic degradation by host collagenolytic enzymes, matrix metalloproteinases (MMPs) and cysteine cathepsins. Here we review the recent findings demonstrating that inhibition of salivary or dentin endogenous collagenolytic enzymes may provide preventive means against progression of caries or erosion, just as they have been shown to retain the integrity and improve the longevity of resin composite filling bonding to dentin. This paper also presents the case that the organic matrix in caries-affected dentin may not be preserved as intact as previously considered. In partially demineralized dentin, MMPs and cysteine cathepsins with the ability to cleave off the terminal non-helical ends of collagen molecules (telopeptides) may lead to the gradual loss of intramolecular gap areas. This would seriously compromise the matrix ability for intrafibrillar remineralization, which is considered essential in restoring the dentin's mechanical properties. More detailed data of the enzymes responsible and their detailed function in dentin-destructive conditions may not only help to find new and better preventive means, but better preservation of demineralized dentin collagenous matrix may also facilitate true biological remineralization for the better restoration of tooth structural and mechanical integrity and mechanical properties.

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Matrix Metalloproteinases and Other Matrix Proteinases in Relation to Cariology: The Era of ‘Dentin Degradomics'

A new scoring system, the Basic Erosive Wear Examination (BEWE), has been designed to provide a simple tool for use in general practice and to allow comparison to other more discriminative indices. The most severely affected surface in each sextant is recorded with a four level score and the cumulative score classified and matched to risk levels which guide the management of the condition. The BEWE allows re-analysis and integration of results from existing studies and, in time, should initiate a consensus within the scientific community and so avoid continued proliferation of indices. Finally, this process should lead to the development of an internationally accepted, standardised and validated index. The BEWE further aims to increase the awareness of tooth erosion amongst clinicians and general dental practitioners and to provide a guide as to its management.

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Basic Erosive Wear Examination (BEWE): a new scoring system for scientific and clinical needs

Biomineralization is a dynamic, complex, lifelong process by which living organisms control precipitations of inorganic nanocrystals within organic matrices to form unique hybrid biological tissues, for example, enamel, dentin, cementum, and bone. Understanding the process of mineral deposition is important for the development of treatments for mineralization-related diseases and also for the innovation and development of scaffolds. This review provides a thorough overview of the up-to-date information on the theories describing the possible mechanisms and the factors implicated as agonists and antagonists of mineralization. Then, the role of calcium and phosphate ions in the maintenance of teeth and bone health is described. Throughout the life, teeth and bone are at risk of demineralization, with particular emphasis on teeth, due to their anatomical arrangement and location. Teeth are exposed to food, drink, and the microbiota of the mouth; therefore, they have developed a high resistance to localized demineralization that is unmatched by bone. The mechanisms by which demineralization-remineralization process occurs in both teeth and bone and the new therapies/technologies that reverse demineralization or boost remineralization are also scrupulously discussed. Technologies discussed include composites with nano- and micron-sized inorganic minerals that can mimic mechanical properties of the tooth and bone in addition to promoting more natural repair of surrounding tissues. Turning these new technologies to products and practices would improve health care worldwide.

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Demineralization–remineralization dynamics in teeth and bone

The quality of dental care and modern achievements in dental science depend strongly on understanding the properties of teeth and the basic principles and mechanisms involved in their interaction with surrounding media. Erosion is a disorder to which such properties as structural features of tooth, physiological properties of saliva, and extrinsic and intrinsic acidic sources and habits contribute, and all must be carefully considered. The degree of saturation in the surrounding solution, which is determined by pH and calcium and phosphate concentrations, is the driving force for dissolution of dental hard tissue. In relation to caries, with the calcium and phosphate concentrations in plaque fluid, the 'critical pH' below which enamel dissolves is about 5.5. For erosion, the critical pH is lower in products (e.g. yoghurt) containing more calcium and phosphate than plaque fluid and higher when the concentrations are lower. Dental erosion starts by initial softening of the enamel surface followed by loss of volume with a softened layer persisting at the surface of the remaining tissue. Dentine erosion is not clearly understood, so further in vivo studies, including histopathological aspects, are needed. Clinical reports show that exposure to acids combined with an insufficient salivary flow rate results in enhanced dissolution. The effects of these and other interactions result in a permanent ion/substance exchange and reorganisation within the tooth material or at its interface, thus altering its strength and structure. The rate and severity of erosion are determined by the susceptibility of the dental tissues towards dissolution. Because enamel contains less soluble mineral than dentine, it tends to erode more slowly. The chemical mechanisms of erosion are also summarised in this review. Special attention is given to the microscopic and macroscopic histopathology of erosion.

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Dental Erosion – An Overview with Emphasis on Chemical and Histopathological Aspects

The aim of the present study was to evaluate the effects of fluoride on erosive mineral loss in human enamel and dentine using a cyclic de- and remineralisation model in situ. The study was a three-treatment (5 days each) crossover design involving 4 (enamel) or 6 (dentine) healthy volunteers. Samples were recessed in palatal mouth appliances and worn day and night except during meals and were demineralised extraorally with 0.05 M citric acid (pH 2.3) for 6 x 5 min daily. Fluoridation was performed with toothpaste (SnF2/Olaflur; 0.14% F-) for 3 x 5 min daily (toothpaste fluoridation) or with toothpaste in combination with a mouthrinse (SnF2/Olaflur; 0.025% F-) for 3 x 5 min daily and with a gel (NaF/Olaflur, 1.25% F-) on days 1 and 3 instead of the toothpaste (intensive fluoridation). In the control group no fluoridation was performed. Mineral loss (microm) was determined with the use of longitudinal microradiography. In enamel, mineral loss was 40.7 +/- 15.1 microm in the control group, 18.3 +/- 12.4 microm after toothpaste fluoridation and 5.0 +/- 12.2 microm after intensive fluoridation. The respective values for dentine were 49.0 +/- 15.4, 35.0 +/- 15.5 and 19.8 +/- 12.0 microm. All differences were statistically significant (p < or = 0.001). The results indicate that intensive fluoridation is effective in preventing enamel and dentine from mineral loss even under severely erosive conditions.

Effects of two fluoridation measures on erosion progression in human enamel and dentine in situ.

Due to an increased focus on erosive tooth wear (ETW), the European Federation of Conservative Dentistry (EFCD) considered ETW as a relevant topic for generating this consensus report. This report is based on a compilation of the scientific literature, an expert conference, and the approval by the General Assembly of EFCD. ETW is a chemical-mechanical process resulting in a cumulative loss of hard dental tissue not caused by bacteria, and it is characterized by loss of the natural surface morphology and contour of the teeth. A suitable index for classification of ETW is the basic erosive wear examination (BEWE). Regarding the etiology, patient-related factors include the pre-disposition to erosion, reflux, vomiting, drinking and eating habits, as well as medications and dietary supplements. Nutritional factors relate to the composition of foods and beverages, e.g., with low pH and high buffer capacity (major risk factors), and calcium concentration (major protective factor). Occupational factors are exposition of workers to acidic liquids or vapors. Preventive management of ETW aims at reducing or stopping the progression of the lesions. Restorative management aims at reducing symptoms of pain and dentine hypersensitivity, or to restore esthetic and function, but it should only be used in conjunction with preventive strategies. Effective management of ETW includes screening for early signs of ETW and evaluating all etiological factors. ETW is a clinical condition, which calls for the increased attention of the dental community and is a challenge for the cooperation with other medical specialities.

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Consensus report of the European Federation of Conservative Dentistry: erosive tooth wear—diagnosis and management

The advantages, limitations and potential applications of available methods for studying erosion of enamel and dentine are reviewed Special emphasis is placed on the influence of histological differences between the dental hard tissue and the stage of the erosive lesion No method is suitable for all stages of the lesion Factors determining the applicability of the methods are: surface condition of the specimen, type of the experimental model, nature of the lesion, need for longitudinal measurements and type of outcome The most suitable and most widely used methods are: chemical analyses of mineral release and enamel surface hardness for early erosion, and surface profilometry and microradiography for advanced erosion Morphological changes in eroded dental tissue have usually been characterised by scanning electron microscopy Novel methods have also been used, but little is known of their potential and limitations Therefore, there is a need for their further development, evaluation, consolidation and, in particular, validation

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Carolina Ganss

Papers

Basic Erosive Wear Examination (BEWE): a new scoring system for scientific and clinical needs

Dental Erosion – An Overview with Emphasis on Chemical and Histopathological Aspects

Effects of two fluoridation measures on erosion progression in human enamel and dentine in situ.

Consensus report of the European Federation of Conservative Dentistry: erosive tooth wear—diagnosis and management

Methods for the measurement and characterization of erosion in enamel and dentine