Protecting Your Healthy Patients

Acid erosion is becoming increasingly prevalent in today’s dental patients. It is the result of both intrinsic and extrinsic acids weakening the outer layer of mineralized tissue and increasing the potential for abrasion.¹ Intrinsic acids originate in the stomach and can enter the mouth and damage the teeth in cases of gastric reflux or bulimia.² However, the main cause of acid erosion is extrinsic acid, namely the acid found in food and drinks that have become staples in the American diet.³ Dental professionals can now play an even more significant role in helping patients improve their oral health by inquiring about their patients’ eating and lifestyle habits and making the appropriate recommendations through patient education.

HEALTHY LIFESTYLE, UNHEALTHY TEETH

Dental professionals are well aware of the negative effects of sugary food and drinks on teeth. However, many patients with acid erosion are eating surprisingly healthy diets.⁴

TABLE 1. pH LEVELS OF FOODS AND BEVERAGES

FRUITS AND VEGETABLES:
Apples 3.5 – 3.9
Oranges 2.8 – 4.0
Tomatoes 3.7 – 4.7
Bananas 4.5 – 5.2
Blueberries 3.1 – 3.3
Cherries 3.2 – 4.5
Grapes 2.8 – 3.8
Grapefruit 3.0 – 3.7
Peaches 3.3 – 4.0
Pears 3.5 – 4.6
Pineapple 3.2 – 4.1
Plums 2.8 – 4.6
Strawberries 3.0 – 4.2

BEVERAGES:
Coffee 2.4 – 3.3
Tea 4.2
Beer 4.0 – 5.0
Wine 2.3 – 3.8
Soda 2.7 – 3.5
Sports Drinks 2.3 – 4.4

The tooth surface is softened when exposed to a pH level of 6.5 or lower, and enamel and dentin are softened and demineralized with pH levels of 5.5 or below.4 But low pH levels are not just found in soft drinks. Patients who eat diets filled with fruits and vegetables may be in danger of harming their teeth through acid erosion. Apples record pH levels between 3.5-3.9, oranges between 2.8-4.0, tomatoes between 3.7-4.7, and other vegetables between 3.9-5.1. All of these healthy options are low enough to soften and demineralize enamel and dentin, in addition to exposed cementum. See Table 1 for the pH levels of popular foods and drinks.

Lifestyle choices may also signal an acid erosion problem. Many people enjoy coffee at work and sports drinks when exercising. Coffee has a pH level of approximately 5 and sports drinks between 2.3-4.4, both of which are low enough to cause significant demineralization. Other types of drinks fare the same, including beer with pH levels between 4.0-5.0 and wine between 2.3-3.8.

What patients eat is not always the culprit but rather the choices they make in their daily routines that can signify a potential acid erosion problem. Those who brush after every meal may actually be doing more damage to their tooth surfaces. Consuming acidic foods softens and weakens enamel, which makes patients’ teeth more susceptible to abrasion from brushing.⁵

Patients may experience increased dentinal hypersensitivity as a result of enamel wearing away, to the point of leaving the dentin permanently exposed.¹ Tooth whitening also increases hypersensitivity. If patients’ whitening regimen is excessive, dental professionals should provide education on the recommended frequency of tooth whitening, in addition to incorporating fluoride into their daily routine.

DIAGNOSING ACID EROSION

Many younger patients living a modern, active lifestyle who strive to maintain a healthy mouth and good overall health may be experiencing acid erosion and not know it.

There are other signs dental professionals can look for to determine if acid erosion is occurring. The tooth surface can lose its luster and texture, becoming smooth and rounded as the enamel wears away.⁷ Changes in color may be noticeable, as the thinning enamel allows a deeper-colored dentin to show through and give the tooth a yellow appearance. The incisal edges of the tooth may become thinner and there may be increased translucency on the incisors. The tooth’s structure may also change, with small cracks and minor fractures appearing as a result of the thinning tooth structure. Changes to the tooth’s shape may become apparent, with notch-shaped spaces developing in the cervical region and a cupped or cratered appearance on the occlusal surfaces.

COUNSELING PATIENTS

More people are choosing to eat healthy diets and maintain wholesome lifestyles. However, many do not stop to realize the harmful effects some of these healthy but acidic foods have on their teeth. Acid erosion is an irreversible process. If steps are not taken to reduce wear on teeth, the erosion will continue, causing further long-term damage.

Dental professionals have a responsibility to stress the importance of protecting teeth from acid erosion. Patient recommendations should include reducing exposure to acidic food and drinks and avoiding erosion-inducing habits such as sipping, swishing, or holding drinks in the mouth. Additionally, avoiding tooth brushing immediately following acidic consumption should be discussed and toothbrush technique should be reviewed.⁵ Options available to patients with acid erosion include both in-office and patient-applied medicaments. Such products can help reharden softened tooth enamel and protect against sensitivity that can result from tooth wear.

REFERENCES

1. Bartlett DW. The role of erosion in tooth wear: aetiology, prevention and management. Int Dent J. 2005;55(4 Suppl 1):277-284.
2. Addy M. Dentin hypersensitivity: new perspectives on an old problem. Int Dent J. 2002;52:366-396.
3. Gleason P, Suitor C. Using Dietary Reference Intake-based methods to estimate the prevalence of inadequate nutrient intake among school-aged children. J Am Diet Assoc. 2002;102:530-536.
4. Zero DT, Lussi A. Erosion—chemical and biological factors of importance to the dental practitioner. Int Dent J. 2005:55(4 Suppl 1):285-290.
5. Attin T, Siegel S, Buchalla W, Lennon AM, Hannig C, Becker K. Brushing abrasion of softened and remineralised dentin: an in situ study. Caries Res. 2004;38:62-66.
6. Amaechi BT, Higham SM. Dental erosion: possible approaches to prevention and control. J Dent. 2005;33:243-252.
7. Yip KH, Smales RJ, Kaidonis JA. Case report: management of tooth tissue loss from intrinsic acid erosion. Eur J Prosthodont Rest Dent. 2003;11:101-106.

From Dimensions of Dental Hygiene. April;6(4): 38-39.