A method to measure clinical erosion: the effect of orange juice consumption on erosion of enamel

Erosion and attrition of human enamel in vitro part I: interaction effects

OBJECTIVE

The aim of the study in vitro was to measure the interplay of attrition and erosion of human enamel under several different pH conditions.

MATERIALS AND METHODS

Cusp and smooth surface enamel specimens were prepared from unerupted human third molar teeth. Cusp and smooth surface specimens opposed each other in a wear machine under a load of 600 g. The machine simulated tooth grinding for 30 min (2280 wear cycles). Six groups of 10 specimens were worn in the following environmental conditions: saline, citric acid at pH values of 3.2, 5.5 or 7.0 and two cycling groups (pH 3.2/saline or saline/pH 3.2). Additionally, 10 smooth surface specimens were exposed to the same fluids without attrition. Tissue loss on smooth surface specimens was determined by profilometry. The worn specimen surfaces were studied by SEM.

RESULTS

Attrition depth in saline and pH 7.0 citric acid was 25.5 microm. At pH 3.2 and 5.5 attrition depths were 6.0 and 4.3 microm, respectively. Cycling in saline/citric acid and vice versa produced attrition depths of 9.2 and 7.9 microm, respectively. In the erosion only specimens lesion depths were 3.0, 1.2 and 0 microm at pH 3.2, 5.5 and 7.0 and saline, respectively. Attrition specimens at pH 7.0 and in saline showed very rough surfaces. At low pH enamel surfaces appeared flat and smooth.

CONCLUSIONS

Enamel wear in neutral conditions is significantly higher than in acidic conditions (p < 0.05), apparently due to a smoothing effect of erosion on contacting surfaces.

Influence of Soft Drinks on the Thickness and Morphology of in Situ Acquired Pellicle Layer on Enamel

Diet-induced demineralization is a key factor in tooth enamel loss, with soft drinks being a significant aetiological agent. In the oral environment, the acquired pellicle layer might modify the demineralization potential of drinks. The objectives of this exploratory in situ study were to determine the influence of soft drinks, volunteers, and exposure times on the thickness and morphology of pellicle layers using an atomic force microscope (AFM). Polished uninterrupted third molars were partly taped and exposed to the oral environment for periods of 2 and 5 days, respectively. Each day 1L of either mineral water, a "toothkind" blackcurrant drink, a "prototype" blackcurrant drink, or orange juice was consumed in this four-way crossover, single-center study. Subsequently the tape was removed and the surfaces imaged with an AFM before and after chemical cleaning. The pellicle layer morphology and thickness were investigated. The maximum pellicle layer thickness was observed after the consumption of the prototype blackcurrant drink, followed by the toothkind blackcurrant drink, orange juice, and water on days 2 and 5, respectively. A three-way ANOVA at the 95% confidence level showed statistically significant differences between the pellicle layer thicknesses, factors being drinks (p=0.0046), exposure time (p=0.0009), and volunteers (p=0.0244). Depending on the volunteer either a uniform or a patchy pellicle layer was observed. This demonstrates that AFM is a useful tool in obtaining simultaneously qualitative and quantitative data of in situ acquired pellicle layers.

Cervical tooth wear and sensitivity: erosion, softening and rehardening of dentine; effects of pH, time and ultrasonication

BACKGROUND

Cervical dentine wear is commonly observed and may be associated with dentine hypersensitivity. Erosion is thought to play a part in both conditions but compared to enamel has been little studied in dentine.

AIM

The aims of these studies in vitro were to: (i) determine the effects of citric acid on dentine at different pH values and over time; (ii) measure the depth of dentine demineralisation or softening using ultrasonication; (iii) determine whether softened dentine can be remineralised or rehardened using artificial saliva.

METHODS

Groups of flat dentine specimens prepared from unerupted human third molar teeth were: (a) exposed to citric acid at pH 3.2 for periods up to 4 h with mineral water as control; (b) exposed to citric acid at pH 2.54, 3.2, 4.5, 5.5 and 6.0 for 2 h and then subjected to ultrasonication stepwise up to 480 s; (c) exposed to citric acid at pH 2.54, 3.2, and 4.5, placed into artificial saliva for 24 h and then subjected to ultrasonication as in (b). Loss of dentine was measured by profilometry, after, each phase of erosion, ultrasonication and immersion in artificial saliva.

RESULTS

Depth of erosion significantly increased non-linearly with time and significantly decreased with increasing pH. Ultrasonication had minimal albeit significant effects on control specimens. Removal of softened dentine increased with ultrasonication time. Depth of softening significantly increased with increasing erosion time to 2 h, plateauing at 2 microm. Depth of softening increased to 2 microm from pH 2.54 to pH 3.2 and decreased at higher pH values thereafter. 24 h in artificial saliva provided no protection to the soften zone against ultrasonicaion. Citric acid at all pH values and exposure times removed the dentine smear layer to expose tubules. Ultrasonication did not remove the smear layer on control specimens but removed all deposits formed after exposure to artificial saliva.

CONCLUSION

It is concluded that dentine is susceptible to erosion even at relatively high pH, the tubule system is readily exposed and dentine, unlike enamel, shows little propensity to remineralise.

The effect of pH on the erosion of dentine and enamel by dietary acids in vitro

The reported incidence of tooth erosion caused by acidic soft drinks has been increasingly documented. Citric and phosphoric acids are the two main dietary acids present in these soft drinks. Many variables need to be determined in order to assess risk factors for dental erosion caused by beverage consumption including pH, titratable acidity, pKa, buffering capacity, hence the aim of these in vitro investigations. Methodologies included profiling flat enamel and dentine samples (< +/- 0.3 microm profile) from unerupted human third molars. Groups of five specimens were placed in acidic solutions adjusted with alkali over the available pH range; citric, phosphoric and hydrochloric acid were adjusted with sodium hydroxide and citric acid with trisodium citrate. Tissue loss was calculated by profilometry. Results showed that under these conditions citric acid caused far more erosion over the pH range employed than phosphoric acid for both tissue types. Citric acid compared with hydrochloric acid highlighted dissolution and chelation effects. Phosphoric acid caused minimal erosion over pH 3 for enamel and pH 4 for dentine. These factors could be considered in order to reduce the erosivity of acidic soft drinks.

The erosive effect of herbal tea on dental enamel

OBJECTIVES

The aim of this study was to determine whether conventional black tea and a herbal tea were capable of eroding dental enamel. A further aim was to investigate whether herbal tea of the type tested eroded dental hard tissues to a greater or lesser extent than conventional black tea.

METHODS

Three groups of 21 teeth were exposed to a conventional black tea Typhoo (Group A), a herbal tea Twinings Blackcurrant, Ginsing and Vanilla (Group B) and water, which acted as a control (Group C). Sequential profilometric tracings of the specimens were taken, superimposed and the degree of enamel loss calculated as the area of disparity between the tracings before and after exposure.

RESULTS

Conventional black tea and herbal tea, of the type tested, both resulted in tooth surface loss. Tooth surface loss, which resulted from exposure to herbal tea (mean 0.05mm(2), s.d. 0.02), however, was significantly greater (P=0.00) than that which resulted from exposure to conventional black tea (mean 0.01mm(2), s.d. 0.00) and water (mean 0.00mm(2), s.d. 0.00).

CONCLUSIONS

It was concluded that herbal tea and conventional black tea of the type tested result in erosion of dental enamel. The erosive effect of the herbal tea of the type tested was five times more severe than that of the conventional black tea tested. The cumulative effects of regular consumption of herbal tea of the type tested are likely, therefore, to be of clinical significance.

The erosive effects of some mouthrinses on enamel. A study in situ

BACKGROUND

There are both anecdotal clinical and laboratory experimental data suggesting that low pH mouthrinses cause dental erosion. This evidence is particularly relevant to acidified sodium chlorite (ASC) formulations since they have plaque inhibitory properties comparable to chlorhexidine but without the well known local side effects.

AIM

Studies in situ and in vitro were planned to measure enamel erosion by low pH mouthrinses. The study in situ measured enamel erosion by ASC, essential oil and hexetidine mouthrinses over 15-day study periods. The study was a 5 treatment, single blind cross over design involving 15 healthy subjects using orange juice, as a drink, and water, as a rinse, as positive and negative controls respectively. 2 enamel specimens from unerupted human third molar teeth were placed in the palatal area of upper removable acrylic appliances which were worn from 9 a.m. to 5 p.m., Monday to Friday for 3 weeks. Rinses were used 2x daily and 250 ml volumes of orange juice were imbibed 4x daily. Enamel loss was determined by profilometry on days 5, 10 and 15. The study in vitro involved immersing specimens in the 4 test solutions together with a reduced acid ASC formulation for a period of 4 h under constant stirring; Enamel loss was measured by profilometry every hour.

RESULTS

Enamel loss was in situ progressive over time with the 3 rinses and orange juice but negligible with water. ASC produced similar erosion to orange juice and significantly more than the two proprietary rinses and water. The essential oil and hexetidine rinses produced similar erosion and significantly more than water. Enamel loss in vitro was progressive over time, and the order from low to high erosion was reduced acid ASC, ASC, Essential oil, and hexetidine mouthrinses and orange juice.

CONCLUSION

Based on the study in situ, it is recommended that low pH mouthrinses should not be considered for long term or continuous use and never as pre-brushing rinses. In view of the plaque inhibitory efficacy of ASC, short- to medium-term applications similar to those of chlorhexidine would be envisaged.

Structured review of enamel erosion literature (1980-1998): a critical appraisal of experimental, clinical and review publications

OBJECTIVE

To attain an objective account of the methods to measure enamel erosion used in 1980-1998 publications, a structured review of the literature was undertaken.

METHODS

Inclusion and exclusion criteria were applied to 731 clinical/experimental research and review reports. Eighty-five included papers were subsequently rated according to 'hierarchy of evidence' guidelines to assess the strength of the report's design and the relevance of the evidence to replicating enamel erosion in vivo in humans. Scores were assigned to rate each aspect in the guidelines.

RESULTS

A total of 16 clinical, 13 review and 56 experimental papers were assessed; 36.4% were published during 1996-1998. Excluding reviews, 16 papers were qualitative and 56 quantitative; 51 used human enamel. Our classification yielded nine groups of methods (five scoring systems and 26 measurement techniques). CTFPHE (Can Med Assoc J 1992; 147: 443) grading of research reports indicated that 2.8% provided evidence grade I; 20.8%, grade IIa; 63.9%, grade III; and 12.5%, grade IV.

CONCLUSIONS

There has been a consistent increase in the body of knowledge. The overall quality of publications has not substantially changed over time. Experimental studies were more often quantitative, and quantitative studies had better research designs. No single group of research methods had obviously superior research designs.

Relative susceptibility of deciduous and permanent dental hard tissues to erosion by a low pH fruit drink in vitro

OBJECTIVES

The objectives of this study were two-fold: (1) to determine (by surfometry) loss of deciduous and permanent enamel and dentine following 15days' exposure to a single low pH orange drink; and (2) to determine (by surfometry) loss of deciduous and permanent enamel and dentine following exposure to the product 2 versus 4 times per day for 15days.

METHODS

This in vitro study employed the validated methodology described by West and co-workers [Journal of Dentistry, 1998;26:329-335.]

RESULTS

In all four tissues, erosion was progressive over time, though this pattern was more linear in enamel than in dentine. In general, erosion of enamel was greater in the deciduous tissue, while erosion of dentine was greater in the permanent tissue. However, these differences were rarely of statistical significance. Increasing frequency of exposure resulted in a non-proportional increase in tissue loss.

CONCLUSIONS

Differences in susceptibility of deciduous and permanent tissues to erosion by a low pH drink in vitro appear to exist, though these may not be of statistical significance. Care may be indicated in the delivery of dietary advice, since reduced frequency of exposure to a low pH drink does not appear to result in a proportional reduction in tissue loss.

Erosion of deciduous and permanent dental hard tissue in the oral environment

OBJECTIVES

The objectives of this study were two-fold: (1) to determine (by surfometry) loss of deciduous and permanent enamel and dentine following consumption of a single low pH orange drink for 15days; and (2) to determine (by surfometry) loss of deciduous and permanent enamel and dentine following consumption of the product 2 versus 4 times per day for 15days.

METHODS

Sixteen healthy volunteers participated in a single centre, single blind, 2-phase crossover study, conducted according to Good Clinical Practice, and employing the validated model described by West and co-workers (Journal of Dentistry 1998; 26:329-335).

RESULTS

In all tissues, erosion was progressive over time, the pattern being more linear in enamel than in dentine. In general, erosion of deciduous enamel was greater than that of permanent enamel, though this difference was significant only for those specimens exposed to 4 drinks per day. Conversely, erosion of dentine was generally greater in the permanent tissue, though differences rarely reached conventional levels of statistical significance. Increasing frequency of consumption resulted in increased loss of tissue, but this difference was neither proportional nor consistently statistically significant.

CONCLUSIONS

It is concluded that statistically significant differences in susceptibility of deciduous and permanent enamel to erosion appear to emerge over time and with increasing frequency of consumption. This is of importance clinically given the reduced dimensions of the deciduous dentition and the element of 'abuse' of soft drinks by the child population. Further development of soft drinks with low erosive potential is recommended.

Effects of pH and concentration of citric, malic and lactic acids on enamel, in vitro

OBJECTIVE

Dental erosion associated with soft drink consumption probably results from the contained dietary acids in the formulations. The pH value of any formulation is an important variable in acid erosion but not necessarily the only important factor. The aim of this study was to measure enamel erosion by citric, malic and lactic acids at pH values and acid concentrations representative of a range found in soft drink formulations and to determine the effect of adding calcium to citric acid.

METHODS

Flat ground enamel samples were prepared from unerupted human third molar teeth. Groups of five specimens were placed in citric, malic and lactic acid solutions of different pH and acid concentration for three by 10 min exposures at 35 degrees C. Enamel loss was measured by profilometry. Enamel specimens were also exposed to citric acid solutions containing calcium at different pH values and at the same pH with different concentrations of calcium.

RESULTS

Numerical data and contour plots for each acid showed a similar pattern for increasing erosion with decreasing pH and increasing acid concentration and vice versa for decreasing erosion. Increasing the concentration of calcium in a fixed pH citric acid solution resulted in decreased erosion. This effect was most marked at higher pH.

CONCLUSIONS

This study has shown that under highly controlled conditions the erosion of enamel by solutions of dietary acids is influenced by the interplay of pH, acid concentration and presence of calcium. These variables and in particular the concentration of calcium could be manipulated to produce soft drinks with reduced erosivity to enamel.

Development and evaluation of a low erosive blackcurrant juice drink. 2. Comparison with a conventional blackcurrant juice drink and orange juice

OBJECTIVE

A previous study demonstrated that an experimental low pH blackcurrant juice drink with calcium was markedly less erosive to enamel both in situ and in vitro than orange juice. Further development of the experimental blackcurrant juice drink formula has occurred and the aims of the present studies were two fold. Firstly, to confirm the low erosivity of the modified formulation and secondly, to provide more comparative data with other acidic fruit drink products.

METHOD

The study was a single centre, single blind, randomised placebo controlled 4 cell crossover design involving 12 healthy volunteers. The test drinks were orange juice, water, experimental blackcurrant juice drink with calcium and a proprietary blackcurrant juice drink. Enamel samples were retained in situ at the mid palatal regions using intraoral appliances and exposed to 250 ml volumes of the drinks 4 times per day during 15 working days. Measurements of enamel loss were made by profilometry. The same method was modelled in vitro.

RESULTS

By day 15 the mean losses of enamel in situ for orange juice, water, experimental blackcurrant juice drink with calcium and blackcurrant juice drink were 1.70, 0.05, 0.44 and 2.75 microns respectively. At all bar one measurement, the loss of enamel was significantly greater for all fruit drinks compared to water. Losses caused by the blackcurrant juice drink with calcium were significantly less than the other two fruit drinks at all time points. Losses of enamel by day 15 in the study in vitro were 13.02, 0.00, 1.78 and 39.02 microns respectively. The blackcurrant juice drink with calcium was not significantly different from water at days 3 and 6, otherwise all pairwise comparisons for differences between the 4 drinks at each time period were significant.

CONCLUSIONS

The methodologies in situ and in vitro again appear to correlate in ranking the order of erosivity of drinks. The data particularly from the study in situ allude to the very low comparative erosivity of the further modified experimental blackcurrant juice drink with calcium and support the further development of such drinks for public consumption.

Development and evaluation of a low erosive blackcurrant juice drink. 3. Final drink and concentrate, formulae comparisons in situ and overview of the concept

OBJECTIVE

Two previous studies demonstrated that a blackcurrant juice drink with added calcium produced little erosion of enamel in vitro and in situ by comparison with other low pH fruit drinks. The primary aim of this study was to demonstrate that the final formulation drink and concentrate were of similar low erosivity. Secondary aims were to provide more data on the erosivity of other fruit drink concentrates and whether erosion was influenced by anterior and posterior palate siting of enamel specimens.

METHOD

The study was a single centre, single blind, randomised placebo controlled 5 cell crossover design involving 15 volunteers. The test drinks were blackcurrant juice/calcium concentrate, blackcurrant juice/calcium drink, proprietary apple & blackcurrant juice concentrate, proprietary orange drink concentrate and water. Four enamel samples were retained in situ, 2 anterior palate and 2 mid/posterior palate, on upper removable acrylic appliances. Drinks were 250 ml volumes consumed 4 times per day during 15 working days. Concentrates were diluted 50 ml in 200 ml water. Measurements of enamel loss were made on one anterior and one posterior sample on days 2, 5, 10 and 15 by profilometry.

RESULTS

One subject approached the 20 microns erosion limit by day 10 on the orange drink and was withdrawn from that cell. Differences in mean erosion between anterior and posterior sites were variable and small. By day 15 the mean losses of enamel averaged over anterior and posterior were blackcurrant/calcium concentrate 0.28 micron, blackcurrant/calcium drink 0.35 micron, apple & blackcurrant concentrate 2.04 microns. orange concentrate 8.29 microns and water 0.08 micron. Except at day 15 for the blackcurrant/calcium drink the erosion by the blackcurrant/calcium formulations was not significantly different from water at any time point. Erosion by the apple & blackcurrant and orange concentrate drinks was highly significantly greater than the blackcurrant/calcium drinks at all but the 2 day time point for the apple & blackcurrant concentrate drink compared to the blackcurrant/calcium drink.

CONCLUSIONS

All data thus far indicate that dependant on tooth site susceptibility and the specific drink, the consumption of standard low pH fruit drinks could result in 1 mm loss of enamel in periods ranging from as little as 2 years to 20 years. Similar erosion by the low pH blackcurrant drinks with added calcium would take in excess of 100 years.

Development and evaluation of a low erosive blackcurrant juice drink in vitro and in situ. 1. Comparison with orange juice

OBJECTIVE

The aim of this study was to determine whether an experimental blackcurrant juice drink with added calcium was less erosive to enamel both in vitro and in situ compared with a proprietary orange juice product.

METHODS

The study was a single centre, blind, randomised, placebo controlled three cell crossover design. An intra oral appliance capable of retaining one enamel sample in situ was constructed and worn by 12 volunteers. The drinks under test were orange juice, the experimental blackcurrant juice drink with calcium and water. Drinks were consumed as 250 ml volumes four times during the working day under supervision for 15 days. The same methodology was modelled in vitro. Measurements of enamel loss were made by profilometry.

RESULTS

Water, the experimental blackcurrant juice drink and orange juice produced 0.19, 0.41 and 2.54 microns loss of enamel respectively in situ and 0.0, 5.2 and 22.18 microns loss of enamel respectively in vitro. All differences between pairs of drinks in situ and in vitro were statistically significant.

CONCLUSIONS

Data using this model in situ were only available for orange juice and this was therefore considered as a positive control with water a placebo control. The results have demonstrated that the experimental blackcurrant juice drink with calcium is markedly less erosive than orange juice, particularly and importantly in situ. The experimental blackcurrant juice drink has limited erosive potential to teeth and deserves further comparative investigation and development as a low pH fruit drink for public consumption.