ONE OF MY PATIENTS DRINKS A LOT OF DIET SODA, WHICH HAS SOFTENED HER TOOTH ENAMEL. WHAT ADVICE SHOULD I GIVE HER ON CHOOSING A TOOTHPASTE THAT WILL SUPPORT ORAL HEALTH BUT NOT BE TOO ABRASIVE?
This patient’s enamel is “soft” because of the demineralization process that occurs each time she drinks the soda, causing an acid attack on the outer layer of the tooth surface. First and foremost, the patient needs to be educated about the sensitive balance between destructive and protective factors that both destroy and protect the tooth. She needs to understand the correlation between acid and caries production, and the importance of frequency and timing of soda consumption. Encouraging behavior change through the use of motivational interviewing will be more beneficial than just changing toothpastes. That being said, your patient needs to be remineralizing her enamel through topical fluoride saturation, while preventing abrasion to the soft enamel. Secondarily, tooth wear is multifactorial, so the toothpaste, amount of pressure placed on the toothbrush when brushing, and dietary habits need to be considered.
Most toothpastes contain particles that help remove daily extrinsic stains that develop over time. These particles come in various shapes and sizes, and cause different amounts of abrasivity. Abrasivity of particles in toothpaste wasn’t assessed until the late 1940s, and in the mid-1970s, abrasivity became standardized by the American Dental Association (ADA). In 1995, the ADA stated that toothpastes should not exceed a relative dentin abrasion (RDA) of 250, which is considered the “upper safe lifetime use limit.” However, it is best to use a toothpaste with the lowest effective RDA to limit iatrogenic erosion and decrease abrasion of the soft enamel. Sodium bicarbonate dentifrices frequently have RDAs below 80 (due to very low hardness of sodium bicarbonate itself). Your patient may benefit from using a sodium bicarbonate toothpaste with fluoride due to her softened enamel.1
In addition, the patient should be instructed to use a power toothbrush with a pressure sensor to prevent additional abrasion caused by aggressive toothbrushing. Incorporating a 0.02% over-the-counter fluoride mouthrinse is also helpful to reverse and arrest noncavitated carious lesions. Finally, for the reversal and arrest of noncavitated carious lesions, the ADA recommends the use of 5% fluoride varnish placed topically every 3 months to 6 months.
As such, the best treatment plan for your patient includes:
- Nutritional and dietary counseling in which goals are established to encourage a decrease in soda intake to one time to two times a day, sipped all at once, and through a straw.
- Use of a low abrasive toothpaste used two times a day that includes the specific directions of brushing and expectorating, but not rinsing out the mouth after brushing.
- Use of a power toothbrush with pressure indicators.
- Addition of a 0.02% fluoride mouthrinse used once daily after drinking the diet soda to aid in the enamel remineralization and acid neutralization process. I would advise the patient to rinse his/her mouth out with water before rinsing with the fluoride mouthrinse.
- Preventive care appointment frequency should be changed from every 6 months to every 3 months.
Following this kind of a person-centered self-care management plan can be difficult for both the patient and the clinician. However, we know that soft enamel can be reversed and even arrested when care is taken to encourage and motivate patient behavior changes and employ powerful evidence-based remineralization strategies.
- Madeswaran S, Jayachandran S. Sodium bicarbonate: a review and its uses in dentistry. Ind J Dent Res. 2018;29:672.
From Dimensions of Dental Hygiene. July/August 2020;18(7):46.