Erosion of tooth enamel

One of the most common non-carious dental lesions - tooth enamel erosion - is the gradual and sustained destruction of the outer protective shell of the tooth. Pathology predominantly affects the convex parts of the surface of the teeth and manifests itself in the form of rounded defects of different depths and diameters.

It should be noted that tooth enamel erosion is not only a cosmetic problem. In the absence of treatment, the damage is constantly progressing, aggravating, which further leads to the destruction of both the enamel layer and dentin. In addition, other initially healthy teeth are inevitably involved in the process. [1]

Treatment of pathology is complex.

Epidemiology

In the majority of cases, tooth enamel erosion is localized in the area of the vestibular surface of the lateral and central maxillary incisors. The premolars and canines on the upper and lower jaw are much less likely to be damaged.

Erosion is usually found in the form of a kind of round or oval defect. The lesion affects at least two symmetrical teeth.

The average diametrical dimensions of erosive foci are 1-2 mm, however, in some patients, damage to the entire dental vestibular surface is noted.

Erosion of tooth enamel was first described in the 18th century. Pathology can affect both milk and permanent teeth (however, permanent teeth suffer much more often). The average age of the sick is 30-50 years. The spread of the disease is, according to various sources, from 2 to 42%. Women and men get sick with about the same frequency. [2]

Causes of the erosion of tooth enamel

Dentists do not yet know absolutely all the reasons for the formation of tooth enamel erosion. Therefore, at the moment, the pathology is being actively studied, and the etiology of its development is being investigated. However, some causes are already known: they belong to three categories of factors, such as chemical, mechanical and internal stimuli:

• the use of aggressive oral and dental care products (homemade and whitening pastes, powder, rinse aid);
• internal diseases (pathology of the thyroid gland, diseases of the stomach and duodenum 12, frequent vomiting, increased acidity of gastric juice);
• occupational hazards affecting the composition of salivary fluid;
• regular consumption of acidic foods, pickles, vinegar, carbonated drinks;
• excessive load on the dental coating, which is typical for patients with malocclusion, injuries to the teeth and jaws, wearing mouth guards and other factors that affect the unevenness of chewing and distribution of food in the oral cavity;
• systematic intake of medications containing acetylsalicylic, ascorbic or folic acid;
• regular inhalation of acid vapors, metal or mineral dust.

In childhood, the appearance of erosions is often associated with the abuse of drinks containing sugar and acids. In particular, we are talking about juices, carbonated drinks, compotes. Other reasons can also be improper dental care or lack thereof, malocclusion. [3]

Risk factors

Tooth enamel is a durable mineral layer that is virtually indestructible. However, under the influence of certain factors, the process of its self-destruction is launched: it can continue for many years in a row until it reveals itself to be obvious pathological changes.

Experts identify several basic factors that can affect the appearance of tooth enamel erosion:

• The mechanical factor implies the regular use of too powerful toothpastes and other preparations for cleaning teeth. The problem can arise with systematic bleaching procedures, using mouth guards. Such a bad habit as bruxism - frequent grinding of teeth, especially at night, also makes its contribution.
• The chemical factor lies in the regular ingress of various acids and alkalis on the tooth enamel (including food ones, such as fruit juices, vinegar, citric acid, sweet carbonated drinks like "Coca-Cola" or "Pepsi"). [4], [5]
• Internal or endocrine factor is caused by malfunctioning of the thyroid gland. Many people suffering from thyrotoxicosis have changes in the composition of salivary fluid, which directly affects the damage to the tooth enamel.

Other factors include an excessive enthusiasm for vitamin preparations (especially large doses of vitamin C and folic acid), malocclusion, infectious lesions of the oral and nasal mucosa. In some patients, there was a genetic predisposition to the appearance of tooth enamel erosion. [6]

Pathogenesis

Erosion of tooth enamel develops according to the following pathological stages:

• The active stage is accompanied by an increasing thinning of the protective layer of the tooth, which entails an increased sensitivity of the teeth to the effects of various stimuli. The destruction of the enamel layer usually occurs intensively, erosion gradually increases.
• The stabilized stage is slower than the active stage. The pain is moderate, which is due to the formation of tertiary dentin - a waste product of the pulp, which becomes a kind of protective layer.

These stages can be repeated, alternating with each other.

In addition to stages, there are four main phases in the development of tooth enamel erosion:

1. The initial phase is characterized by damage to only the upper enamel layer.
2. The middle phase is accompanied by deep damage to the enamel, up to dentin.
3. The deep phase is a complete defeat of the enamel layer and the upper layer of dentin, with the formation of secondary dentin.
4. Involvement in the pathological process of the dental pulp.

Erosion of tooth enamel is subdivided into endogenous and exogenous, depending on the etiology of the disease.

Endogenous erosion is spoken of if it occurs as a result of regular repeated vomiting (for example, with eating disorders), increased acidity of gastric juice, gastroesophageal reflux, etc. [7]

Exogenous erosion occurs when foods and liquids with a pH of less than 5.5 are consumed. [8]

Symptoms of the erosion of tooth enamel

At first, the symptomatology of the pathology is insufficiently expressed and attracts attention already at the time of damage to the inner layers of the tooth. In general, the clinical picture depends on the stage of development of erosion.

Usually, erosion is a rounded-oval enamel defect that is located in the transverse direction on a more prominent area of the vestibular surface of the dental crown. With the aggravation of the pathology, the boundaries of erosion deepen and expand, pain appears due to exposure of dentin and exposure to chemical and thermal stimuli.

At the first stage, the enamel coating darkens slightly or becomes dull: to detect the affected area, a drop of iodine can be applied to the tooth, which will allow you to more clearly see the area of damage. There are no pains at the first stage.

The erosive defect itself looks like a rounded bowl-shaped focus, with a hard, smooth and glossy bottom. Gradually, the focus expands, becomes deeper, the enamel layer becomes thinner with further exposure of dentin. The patient has discomfort when hot and cold irritants hit the tooth.

At first, the defect has light shades, but as the process deepens, it becomes light yellow, then brownish.

At a later stage of development, pain appears - while eating, when brushing your teeth. The affected lesions have the appearance of brown deep defects.

Erosion can develop at different rates, which depends on the individual characteristics of the organism, and on the general condition of the teeth, and on the degree and frequency of exposure to provoking factors.

The disease is characterized by a chronic course, gradual progression and further spread to healthy teeth.

For each of their stages of development of erosion, the following first signs are characteristic:

1. The affected area of the tooth enamel becomes dull (loses its shine), which rarely attracts the attention of the patient and even the dentist. The defect can be clearly visualized only by thoroughly drying the tooth surface with a stream of air, or by dropping a drop of iodine tincture on the tooth (the affected lesion becomes colored and turns brown). The usual initial form of the defect is round-oval, the bottom is smooth, the color shade is light. There are no pains at the first stage.
2. Further, discomfort gradually appears (especially while eating), the affected area darkens.
3. Painful sensations intensify, brown spots deepen.

Complications and consequences

The process of formation of tooth enamel erosion can last for several years. However, after the appearance of the first pathological signs, changes on the enamel surface occur quite quickly:

• crowns wear out;
• the color darkens;
• the tooth edges become thinner;
• sensitivity increases, there are problems with eating.

If pathology is not detected in a timely manner and treatment is not started, then it is likely that serious complications will develop - in particular, such as:

• the spread of erosion to the entire tooth and to other healthy teeth;
• loss of uniformity of the color of the enamel layer (the cutting edge may become transparent);
• accelerated erasure of the enamel layer, increased tooth wear;
• increased sensitivity to taste and temperature stimuli, the appearance of pain.

When the pathological process spreads to the hard tissue of the tooth (dentin), then its intensive destruction occurs. As a result, other dental pathologies develop. [9]

Diagnostics of the erosion of tooth enamel

Diagnostic measures for suspected erosion of tooth enamel begin with an examination and consultation with a dentist. Standard diagnostics consists in carrying out the following procedures:

• External examination of the oral cavity and dentition allows the doctor to determine the presence of violations, to distinguish them from other dental diseases. In some cases, the doctor is able to identify the causes of the pathology already at the first visit.
• Testing with drying the affected lesion with a stream of air and applying iodine helps to clearly visualize the areas of spread of erosion.
• Ultrasound examination of the thyroid gland and the study of hormonal levels, diagnostics of the digestive system help to clarify the connection between the appearance of erosions with other pathologies in the body. [10]

Differential diagnosis

Diagnostic measures must be complete and thorough, as the disease is often confused with other dental pathologies.

Erosion of tooth enamel is distinguished, first of all, from necrosis of hard tissues of the teeth, from caries and wedge-shaped defect.

With caries, the roughness of the enamel layer is noted, while with erosion it is smooth.

A wedge-shaped defect  occurs in the root area of the teeth, while the crowns change their shape.

For necrosis of hard tissues, the appearance of chalky spots on the enamel, exfoliation of some areas when using a probe is characteristic.

Treatment of the erosion of tooth enamel

In general, the treatment of patients with tooth enamel erosion is carried out taking into account the following mandatory principles:

• Consultations with a gastroenterologist, neuropathologist, endocrinologist with further appropriate treatment of the detected disorders.
• Dental treatment using measures that increase the resistance of tooth enamel to acidic influences.
• Professional treatment of the oral cavity without the use of aggressive and abrasive agents (twice a year).
• Course remineralizing therapy with further fluoridation (two courses of treatment, 15 procedures each). Between courses, chewable vitamin-mineral complex preparations are prescribed (ROCS Medical, three tablets a day for a month).
• Direct and indirect restorative restoration of visible dental defects.
• Dispensary control by specialized specialists (dentist, gastroenterologist, neuropathologist, endocrinologist).

In addition to the main treatment, the patient's diet must be adjusted. Exclude fruits and citrus fruits, carbonated drinks, sour berries. After consuming any acidic foods, it is recommended to rinse the mouth (without brushing your teeth). The teeth are brushed in the morning and in the evening using a soft brush and paste with a reduced RDA index. [11]

How to restore enamel in case of tooth erosion?

At an early stage of the appearance of tooth enamel erosion, remineralizing measures are carried out. They involve the application of calcium and fluoride preparations to the affected areas. In general, ten to fifteen such procedures are performed, after which pigmentation is eliminated.

At a late stage in the development of pathology, the course of remineralization and getting rid of pigmentation is completed by filling the defect with the help of composite materials. At the same time, remineralization is considered mandatory, since without this link, the filling will be unreliable, and the erosive area will continue to increase. [12]

The crown restoration scheme is compiled by the doctor individually, depending on the stage of the pathological process and the number of affected teeth.

Medicines

As part of complex therapy, it is possible to use the following drugs:

• Elmex gel is used to remineralize the affected areas of crowns, to desensitize sensitive tissues. It is recommended to brush your teeth with gel once a week (like with a regular paste), with 1 cm of gel applied to a soft brush. Do not swallow the gel! The product is intended for adults and children from six years of age.
• ApaCare Repair gel "liquid enamel" is a strong restorative agent that is applied to the dentition for 1 hour (for pediatric patients - for 15 minutes). During the action of the drug, you must not eat or drink. The procedure is repeated in the morning and evening for four weeks. The product is well tolerated, hypoallergenic, and does not contain fluoride.
• GC Tooth Mousse revitalizing gel in the form of a water-soluble cream containing casein-phosphopeptide-amorphous calcium phosphate. With a superficial application of the gel, additional protection of hard dental tissues is provided, and the increased acidity in the oral cavity is neutralized. The agent is applied in a thick layer to the surface of the crowns, left for three minutes, after which it is distributed with the tongue throughout the oral mucosa. Try not to swallow as long as possible (at least 10-12 minutes) - the result depends on this. Further, refrain from eating food and liquids for half an hour after the procedure.

Dental health, like the health of other systems and organs, is impossible without sufficient intake of vitamin and mineral components in the body. Therefore, doctors often prescribe to patients vitamin-mineral complexes containing calcium and vitamin D: [13]

• Calcimin is prescribed for adults and children from 12 years old, 1 tablet with food 2 times a day. The duration of admission is determined by the doctor. With prolonged use, dyspepsia, allergic reactions are possible.
• Procitracal is a drug that is an additional source of calcium, magnesium, zinc and vitamin D ₃. The treatment regimen is individual.

Toothpaste for erosion of tooth enamel

Damage to tooth enamel and tooth sensitivity are common. That is why the pharmaceutical market is increasingly filled with dental products and pastes, which are positioned as protecting the enamel coating and restoring its structure.

Nine toothpastes were tested by Swiss scientists, 8 of which were supposed to help with erosion, and 1 was a regular hygienic paste (control). Based on the results of the experiment, a disappointing conclusion was made: none of the pastes affected the wear of the enamel layer, which acts as a key link in the development of erosion. [14]

Dentists explain that oral hygiene products are necessary and important to use regularly. However, pastes are just one addition to the holistic approach. As a preventive factor, you can use the following teeth cleaning products:

• EMOFORM-F for sensitive teeth.
• GUM SensiVital.
• Sensodyne Instant effect
• Parodontax with fluoride.
• ROCS
• Elmex Zahnschmelz Schultz Professional.

In general, regular dental consultations are necessary to monitor the health of the oral cavity. Only the doctor after the examination will be able to give recommendations regarding the choice of toothpaste. If you choose the wrong hygiene product, you can not only not get the expected result, but also harm your teeth, and also significantly complicate the subsequent treatment. [15]

Herbal treatment

In most cases, experts do not recommend resorting to the treatment of tooth enamel erosion with alternative means. Although some patients still try to be treated - for example, by such methods:

• Take 1 tbsp. L. Oak bark, pour 200 ml of boiling water, keep on low heat for 6-7 minutes. The resulting broth is cooled and used to rinse the mouth three times a day.
• Pour 1 tbsp. L. Chamomile color 200 ml of boiling water, infused under the lid for 1-1.5 hours. Then the infusion is filtered and used for rinsing at least 5 times a day.
• Take 1 tsp. Dry burdock herb, pour 250 g of boiling water and boil over low heat for three minutes. Insist under the lid for an hour, filter. Used for rinsing up to five times a day.

Dentists point to the low effectiveness of such methods. Certain medicinal plants can actually help relieve pain and soothe sore teeth. However, they are not able to save a person from the problem: meanwhile, precious time will be lost, during which the situation may worsen. [16]

Prevention

Preventive measures to prevent the appearance of erosion of tooth enamel are reduced to the observance of the following rules:

• It is advisable to use a toothbrush of medium hardness: too hard brushes can damage both the gums and the enamel protective surface of the teeth.
• Bleaching and abrasive products are not intended for regular use. Long-term or systematic use of such funds can cause the development of erosion.
• Sour juices and carbonated drinks have an adverse effect on tooth enamel. If you can’t stop consuming them, you can try drinking with a cocktail straw, which will reduce the amount of acid on the surface of your teeth.
• To reduce the adverse effects of acid, you should rinse your mouth with warm water after each meal. It is impossible to brush your teeth with paste immediately after taking acidic food - you need to rinse the mouth, and use the brush after 40-60 minutes.
• Chewing gum is not recommended for more than five minutes.
• Periodically, it is advisable to use special fluorine-containing pastes.

In addition to all of the above, it is imperative to visit the dentist at least every 6 months - for a preventive examination. This will help prevent the development of pathology, or stop it at an early stage. [17], [18]

Forecast

The prognosis for timely medical intervention is conditionally favorable. Subject to all the doctor's prescriptions, a slowdown and arrest of the development of the erosive process is achieved, patients note the absence of pain and an increase in the quality of life. The dentist selects suitable means to improve the aesthetic appearance of teeth, performs procedures for restoring the shape of crowns, and ensures reliable protection of their surface from adverse factors.

Erosion of tooth enamel, detected in the early stages, has a much more beneficial effect. Thanks to complex treatment, it is possible to eliminate the formed defect, restore the aesthetics and functional ability of damaged teeth.