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Enamel Erosion

Overview

Enamel&nbsp;erosion,&nbsp;also known as dental erosion, is the chemical breakdown of the mineralized tooth material enamel that forms the outermost layer of the teeth. 
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The outermost layer of the tooth is enamel. It is a thin, translucent layer that is the hardest tissue in the human body<a href="#accordion">[1]</a>. The translucent enamel covers the dentin, which can be off-white, white, gray, or yellowish, and forms the main portion of the tooth. The color of the tooth is actually the color of the dentin showing through the enamel.

The enamel insulates the tooth from harsh temperatures that may be too hot or cold. It also protects the teeth during the process of chewing, biting, crunching, and grinding. Even though enamel is a hard, protective layer of the tooth, it can still get cracked or chipped off. This is why when the enamel wears off, the tooth becomes sensitive to harsh temperatures and certain chemicals. 
&nbsp;

Moreover, the dentine has tubules that connect to the inner innervation of the tooth, so certain foods and drinks can cause a fluid movement in the tubules and trigger a painful sensation in the nerves.

According to one study on global prevalence, the average prevalence of erosion in adults&#39; permanent teeth ranges from 20-45%, while the incidence rate for deciduous (primary or milk) teeth is 30-50%<a href="#accordion">[2]</a>.

Signs and Symptoms

The initial signs and symptoms of enamel erosion include:

<ul>
	<li>Discoloration&nbsp;- The tooth appears yellow due to greater exposure of the dentin.</li>
	<li>Cupping&nbsp;- The chewing surface of the teeth is affected and small indentations or cups develop at the site.</li>
	<li>Chips Or Cracks - As the enamel erodes, the edges of the teeth become irregular, rough, and jagged.</li>
	<li>Increased Sensitivity&nbsp;- Foods that are hot, cold, or sweet cause sharp pain. 
	&nbsp;</li>
</ul>

A significant enamel erosion will present itself as:

<ul>
	<li>Increased Pain And Sensitivity&nbsp;- Extreme sensitivity to hot, cold, and sweet things along with a sharp, unbearable pain.</li>
	<li>Cupping&nbsp;- Indentations form on the biting and chewing surfaces of the teeth.</li>
	<li>Shiny Or Smooth Surfaces&nbsp;- The tooth appears smooth and shiny due to mineral loss<a href="#accordion">[1]</a>. 
	&nbsp;</li>
</ul>

Causes

The intrinsic causes of enamel erosion are: 
&nbsp;

<ul>
	<li><a href="https://merisehat.pk/disease/gerd-56">Gastroesophageal Reflux Disease (GERD)</a>&nbsp;- Due to persistent regurgitation of stomach contents, GERD is thought to be a health concern for dental erosion. According to certain systematic evaluations, acid regurgitation frequency or intensity&nbsp;may be related to how severely erosive the tooth wear is.</li>
</ul>

Occasional regurgitation is normal, especially after a large meal. However, in individuals with GERD, the acid can come into the mouth during sleep and cover the lower molars (teeth present at the furthest back of the mouth). 
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<ul>
	<li><a href="https://merisehat.pk/disease/bulimia-nervosa">Bulimia</a>&nbsp;- A severe eating problem called bulimia nervosa is characterized by self-inflicted vomiting to maintain a target weight. The prevalence of erosion has been estimated to be around 90% among bulimics.</li>
</ul>

Dentists are frequently the first to identify the illness based on the average weight of bulimic patients and the distinctive erosion of the anterior maxillary teeth brought on by the strong discharge of stomach acids onto the front teeth while vomiting. 
&nbsp;

<ul>
	<li>Chronic Alcoholism -&nbsp;Alcoholism can cause erosive tooth wear if there is frequent vomiting or increased regurgitation. Additionally, drinking acidic beverages can worsen erosion in people who are alcohol-dependent. According to small studies, 49-92% of the teeth of alcoholics exhibit symptoms of erosion. 
	&nbsp;</li>
	<li>Pregnancy&nbsp;- Although tooth erosion during pregnancy is uncommon, it has been observed in women who have hyperemesis gravidarum, a condition where nausea and vomiting can last longer and be more severe. 
	&nbsp;</li>
	<li>Reduced Saliva Or Xerostomia&nbsp;- Dry mouth can cause acids to remain on the teeth instead of being neutralized or washed off with saliva. This leads to enamel erosion. 
	&nbsp;</li>
</ul>

The extrinsic causes of enamel erosion are:

<ul>
	<li>Beverages - A rising body of research indicates that regular drinking of soft drinks, sports drinks, and fruit juices with low pH values (2-3.5 pH) is dangerous for teeth health.</li>
</ul>

A meta-analysis from 2015, found that natural fruit juices, carbonated soft drinks, acidic, sweet snacks, and sweet-sour sweets were all major erosion-predisposing factors. Despite that, 93% of 379 commercially available beverages in the United States had a pH of less than 4.0, according to a 2016 study by Reddy et al. 
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<ul>
	<li>Lifestyle&nbsp;- Increased erosion risk may result from increased ingestion of highly acidic fruit and sports beverages, decreased salivary flow, and dehydration due to intense or athletic exercise. Consumption of caffeine can also reduce saliva production and increase the risk of erosion. 
	&nbsp;</li>
	<li>Environmental And Occupational Causes&nbsp;- Dental erosion among factory employees has been linked to airborne industrial acids, especially in those working with munitions, batteries, and fertilizers. Moreover, it has been observed that swimmers who frequently use chlorinated pools experience higher rates of erosion, which is attributable to the pH of the water. 
	&nbsp;</li>
	<li>Medications - Liquid iron syrup, chemotherapy, cough suppressants, chewable vitamin C tablets, mouth rinses, and asthma medication puffs can all cause dental erosion. 
	&nbsp;</li>
	<li>Incorrect Brushing&nbsp;- Brushing too hard can increase the rate at which enamel wears. It&rsquo;s also important to note here that brushing immediately after a meal, that too with heavy force, damages the enamel. This is because the environment of the mouth is acidic post-meal, which softens and weakens the enamel, making it too weak to withstand the force of the brush<a href="#accordion">[2][3]</a>. 
	&nbsp;</li>
</ul>

Diagnosis

Diagnosing enamel erosion involves a thorough clinical examination, an evaluation of all pertinent risk factors, and a complete health history. During an oral exam, the teeth seem discolored, smooth/shiny, and can have cupping. The detailed history can help identify conditions such as GERD or xerostomia, which could be resulting in erosion. 
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Treatment

The enamel that is lost can unfortunately not grow back or repair itself.

The first step is to put a stop to any further loss of enamel by eliminating the cause. If there are underlying conditions like xerostomia or GERD, they need to be treated by the respective specialist. Meanwhile, dental treatments like fluoride varnish or tooth remineralization can stop further loss of enamel. 
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For the already lost enamel, treatment involves replacement through:

<ul>
	<li>Veneers&nbsp;- customized tooth-colored shells that are placed on the teeth to improve their appearance</li>
	<li>Fillings&nbsp;- tooth-colored filling material to replace any lost surface</li>
	<li>Crowns&nbsp;- a crown gives stability and improves the appearance of the tooth in case the structure loss is severe. 
	&nbsp;</li>
</ul>

The loss of tooth structure may necessitate complicated and extensive dental work, including root canal therapy and tooth extraction<a href="#accordion">[4]</a>. 
&nbsp;

Complications of enamel erosion include:

<ul>
	<li>Caries - The tooth becomes more susceptible to decay once the protective enamel is removed.</li>
	<li>Appearance - The teeth will look more yellow and can have rough edges with a shiny and unnatural appearance.</li>
	<li>Fracture&nbsp;- If the tooth is weakened over a long time by erosion, it could lead to a fracture of the tooth. 
	&nbsp;</li>
</ul>

<ul>
	<li>Demographic Factors &ndash; Nearly 5% of females between the ages of 18 and 35 in Western industrialized countries exhibit symptoms of bulimia, which is known to trigger enamel erosion<a href="#accordion">[2]</a>. 
	&nbsp;</li>
	<li>Health Factors &ndash; Pregnancy, obesity, and intense exercise increase intra-abdominal pressure and cause GERD. Moreover, according to a comprehensive review, patients with eating disorders or self-inflicted vomiting have 5-7 times higher risk of tooth erosion<a href="#accordion">[2]</a>. 
	&nbsp;</li>
	<li>Lifestyle Factors &ndash; Consuming acidic or sugary foods and drinks, such as citrus foods, ice creams, white bread, and soft drinks, can increase the likelihood of enamel erosion. Alcohol abuse and tobacco chewing are other red flags. 
	&nbsp;</li>
	<li>Environmental Factors &ndash; While friction and wear and tear due to age is something that occurs naturally and cannot be avoided, biting on hard objects (e.g., pens, fingernails) or excessive clenching and grinding because of stress can be unhealthy for teeth. 
	&nbsp;</li>
	<li>Genetic Factors &ndash; Acquired pellicle, saliva production, and tooth structure and positioning with respect to the tongue and soft tissues are related to the pathogenesis of dental erosion. 
	&nbsp;</li>
</ul>

Make sure to brush, floss, and use fluoride and antiseptic mouthwash every day to prevent enamel loss and maintain dental health. It&rsquo;s important to visit a dentist for a routine checkup and cleaning every 6 months. 
&nbsp;

The following measures can also help:

<ul>
	<li>Avoid, if not eliminate, acidic sodas and acidic juices from the diet. Rinse the mouth with water after consuming any acidic food item.</li>
	<li>Use a straw to consume acidic drinks so that the drink surpasses the teeth and reaches the throat directly.</li>
	<li>Frequent snacking increases the likelihood of tooth decay because the mouth becomes acidic a few hours after consuming foods high in sugar and carbohydrates. Avoid munching if brushing and rinsing the mouth isn&rsquo;t possible.</li>
	<li>Gum chewing increases saliva production by nearly 10 times. Saliva contains essential elements that help strengthen teeth. Make sure to choose sugar-free gum that contains xylitol, which has been found to lessen the acidity of foods and beverages.</li>
	<li>Drink more water throughout the day to deal with low saliva production.</li>
	<li>Use fluoride toothpaste.</li>
	<li>Use a soft toothbrush and avoid aggressive brushing of the teeth.</li>
	<li>Avoid brushing right after meals; wait at least 30 minutes.</li>
	<li>Avoid brushing right after vomiting.</li>
	<li>Dental sealant protects the teeth from erosion and decay.</li>
	<li>According to research, the presence of calcium and phosphate in milk and yogurt products (which are presumably unsweetened) can have a preventive effect against erosion. Finishing a meal with a glass of milk will cancel out acids<a href="#accordion">[1]</a>. 
	&nbsp;</li>
</ul>

A cross-sectional survey was carried out in South India among schoolchildren aged 11-14 to evaluate the prevalence and severity of dental erosion as well as possible risk factors. Children who regularly ate a lemon and those who preferred carbonated beverages were more likely to experience dental erosion. It was discovered that 65.6% of cases of erosion occurred in posterior teeth compared to 34.4% in anterior teeth. In 94.8% of the cases, enamel loss was only seen in conjunction with surface contour loss. Children in private schools experienced greater dental erosion<a href="#accordion">[5]</a>. 
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Key Points

<ul>
	<li>Enamel&nbsp;erosion,&nbsp;also known as dental erosion, is the chemical breakdown of the mineralized tooth material enamel that forms the outermost layer of the teeth.&nbsp; </li>
	<li>The translucent enamel covers the dentin which can be off-white, white, gray, or yellowish, and forms the main portion of the tooth. The color of the tooth is actually the color of the dentin showing through the enamel. </li>
	<li>Due to persistent regurgitation of stomach contents, gastroesophageal reflux disease is thought to be a health concern for dental erosion.</li>
	<li>Although tooth erosion during pregnancy is uncommon, it has been observed in women who have hyperemesis gravidarum, a condition where nausea and vomiting can last longer and be more severe.</li>
	<li>The enamel that is lost can unfortunately not grow back or repair itself.</li>
</ul>

[1] Tooth enamel: Erosion and restoration. WebMD.

[2] Dental erosion. Dental Erosion | American Dental Association.

[3] Brushing immediately after meals? you may want to wait. Columbia University Irving Medical Center.

[4] Dental erosion. healthdirect.

[5] Kumar S, Acharya S, Mishra P, Debnath N, Vasthare R. Prevalence and risk factors for dental erosion among 11- to 14-year-old school children in South India. Journal of Oral Science. 2013;55(4):329-336. doi:10.2334/josnusd.55.329