Tooth wear and the role of salivary measures in general practice patients

OBJECTIVES

The goal of this study was to investigate the association between tooth wear and salivary measures in a random sample of patients from practices of dentist members of a practice-based research network.

MATERIALS AND METHODS

Patients completed a questionnaire on oral self-care, health, dietary habits, medications, and socio-demographic variables. Six salivary characteristics (consistency, resting salivary flow, resting salivary pH, stimulated salivary flow, stimulated salivary pH, and buffering capacity) were measured, and a dental examination included categorizing patients according to the dentist's judgment of the degree of tooth wear (i.e., none/minimal, some, or severe/extreme). Bivariate and multinomial logistic regression models were used to relate salivary characteristics and other factors to the outcome of tooth wear.

RESULTS

Data are reported from 1,323 patients (age range 16-97 years) from 61 practices. Patient age, gender, number of teeth, and perception of dry mouth were associated with tooth wear, but salivary and dietary factors were either weakly or not related.

CONCLUSIONS

The findings of this cross-sectional assessment suggest that using these salivary tests and dietary assessments in real-life clinical settings is unlikely to be useful in assessing tooth wear risk. Suggestions are offered about risk assessment for tooth wear.

CLINICAL RELEVANCE

Assessing a dental patient's risk of tooth wear using salivary measures and dietary assessments as described is not recommended for general dental practice until stronger evidence exists indicating its utility.

Evaluation of the pH and titratable acidity of teas commercially available in Brazilian market

OBJECTIVE: Tea has been considered a healthy alternative to other industrialized beverages. The objective of this study was to assess the erosive potential of teas commercially available in Brazil by pH and titratable acidity measures. METHODS: Eighteen teas available in Brazilian market were selected for this study (read to drink and brewed tea), and a brand of yerba mate (Ilex paraguariensis). Each product was analyzed for pH and titratable acidity. For comparison between different kinds of teas, the Student t test was used. RESULTS: The mean pH values for ready to drink teas ranged between 2.89 and 4.03, while for the brewed teas and yerba mate the values ranged between 6.75 and 7.89. The difference between the two groups was significant (p < 0.05). Regarding titratable acidity, the ready to drink teas showed mean values ranging between 3.77 ml and 12.68 ml. Brewed teas (including yerba mate) were not tested for titratable acidity because their pH values were greater than 7.0. CONCLUSION: Among the teas commercially available, ready to drink teas have lower pH values and higher titratable acidity compared to other teas. It suggests that they have an erosive potential.

Calcium lactate pre-rinse increased fluoride protection against enamel erosion in a randomized controlled in situ trial

OBJECTIVES

This in situ trial study was designed to evaluate whether calcium (Ca) pre-rinse would increase the fluoride (F) rinse protection against enamel erosion.

METHODS

Fifteen volunteers participated in this split-mouth, 3-phase, crossover design study wearing a palatal appliance containing four sterilized bovine enamel slabs, for 10 days. In the 1st phase, five participants followed protocol A: daily rinse with a Ca lactate (CaL, 150mmol/L, 1min), followed by F (NaF 12mmol/L, 1min). Other five participants followed protocol B: daily rinse only with F, while the remainders followed protocol C: no rinse (negative control). Appliances were removed from the mouth and one side of the palatal appliance was exposed to a daily erosive challenge (0.05M citric acid, 90s); the other side served as control (deionized water - no erosion). In the 2nd phase volunteers were crossed over to other protocol and in the 3rd phase volunteers received the remaining protocol not yet assigned. Specimens were evaluated for surface loss using an optical profilometer.

RESULTS

Repeated-measures three-way ANOVA (p=0.009) and Tukey's test showed that CaL pre-rinse followed by NaF rinse significantly decreased surface loss of enamel when performed prior to an erosive challenge in comparison with the condition in which NaF only was used.

CONCLUSIONS

Pre-rinse with CaL may increase the protection exerted by NaF against erosive wear.

Effects of diode laser therapy and stannous fluoride on dentin resistance under different erosive acid attacks

OBJECTIVE

This in vitro study aimed to evaluate the effect of a low intensity diode laser (λ=808 nm; 60 J/cm2) associated with stannous fluoride on the inhibition of dentin erosion by assessing percentage of superficial hardness loss (%SHL) and calcium release into the acid solution.

MATERIALS AND METHODS

Human root dentin slabs were assigned to eight groups (n=10), according to treatments (control, stannous fluoride, diode laser therapy, and the combination of stannous fluoride and laser therapy), and acid challenge (hydrochloridric or citric acid). All slabs were subjected to a previous 2 h acquired pellicle formation; laser and fluoride treatments were performed according to the groups. Subsequently, the slabs were exposed to erosive challenge (0.01 M hydrochloridric acid or citric acid 1% for 60 sec). Additionally, calcium released into the acid solution during erosive challenge was analyzed by photometric test. Data were analyzed by ANOVA followed by Tukey's test (p<0.05).

RESULTS

Mean values (±SD) for %SHL of treated groups did not present statistically significant differences, regardless of the erosive challenge. However, in relation to released calcium concentration, groups treated with laser presented statistically significant lower calcium loss under hydrochloridric acid challenge (p<0.001). To groups under citric acid attack, only the combination of treatments (p=0.037) was able to show a protective effect on dentin.

CONCLUSIONS

Under the conditions of this study, 808 nm diode laser with or without stannous fluoride could effectively reduce dentin surface loss under both acid exposures. Only calcium concentration analysis was sensitive enough to measure the effects under the tested conditions.

Association between dental erosion and diet in Brazilian adolescents aged from 15 to 19: a population-based study

Dental erosion is a pathological condition resulting from the irreversible dissolution of the mineralized portion of the teeth, being recognized in modern society as an important cause of loss of tooth structure. The aim of this study was to assess the prevalence and its association with diet in Brazilian adolescents of Campina Grande, PB, Brazil. A population-based study was conducted on a stratified sample of 675 adolescents aged from 15 to 19 of both sexes using the index proposed by O'Sullivan. Dental examinations were performed by two calibrated dentists (kappa = 0.82). The significance level adopted was 5%. The prevalence of dental erosion was 21%, and the upper central incisors and lateral incisors were the most affected elements, with 50.5% and 40.2%, respectively. The buccal surface showed greater impairment (51.4%) and 67.8% of teeth with dental erosion had more than half of the surface of affected area. Most damage was on the enamel (93.5%). There were no statistically significant differences between the occurrence of dental erosion and gender, age, socioeconomic status, self-reported ethnicity, and diet. There was high prevalence of dental erosion in its early stages among adolescents and there were no significant differences in the frequency of the consumption of foods and beverages and the presence of dental erosion.

Bioinspired amphiphilic phosphate block copolymers as non-fluoride materials to prevent dental erosion

Inspired by the fact that certain natural proteins, e.g. casein phosphopeptide or amelogenin, are able to prevent tooth erosion (mineral loss) and to enhance tooth remineralization, a synthetic amphiphilic diblock copolymer, containing a hydrophilic methacryloyloxyethyl phosphate block (MOEP) and a hydrophobic methyl methacrylate block (MMA), was designed as a novel non-fluoride agent to prevent tooth erosion under acidic conditions. The structure of the polymer, synthesized by reversible addition-fragment transfer (RAFT) polymerization, was confirmed by gel permeation chromatography (GPC), Fourier transform infrared spectroscopy (FTIR), and nuclear magnetic resonance spectroscopy (NMR). While the hydrophilic PMOEP block within the amphiphilic block copolymer strongly binds to the enamel surface, the PMMA block forms a hydrophobic shell to prevent acid attack on tooth enamel, thus preventing/reducing acid erosion. The polymer treatment not only effectively decreased the mineral loss of hydroxyapatite (HAP) by 36-46% compared to the untreated control, but also protected the surface morphology of the enamel specimen following exposure to acid. Additionally, experimental results confirmed that low pH values and high polymer concentrations facilitate polymer binding. Thus, the preliminary data suggests that this new amphiphilic diblock copolymer has the potential to be used as a non-fluoride ingredient for mouth-rinse or toothpaste to prevent/reduce tooth erosion.

Tooth wear against ceramic crowns in posterior region: a systematic literature review

The objective of this systematic review was to assess tooth wear against ceramic crowns in posterior region in vitro and in vivo. An electronic PubMed search was conducted to identify studies on tooth wear against ceramic crowns in posterior region. The selected studies were analyzed in regard to type of crowns, natural antagonist, measuring protocol and outcome. From a yield of 1 000 titles, 43 articles were selected for full-text analysis; finally, no in vitro and only five in vivo studies met the inclusion criteria. As there is heterogeneity in design, used measuring method, ceramics and analysis-form, a meta-analysis was not possible. Results of these studies are very controversial which makes a scientifically valid comparison impossible. This review indicated that some all-ceramic crowns are as wear friendly as metal-ceramic crowns. Up to now, it has been impossible to associate tooth wear with any specific causal agent. The role of ceramic surface treatment that might be responsible for the changing in rate of tooth wear seems undetermined as yet through clinical trials. The literature reveals that studies on this topic are subject to a substantial amount of bias. Therefore, additional clinical studies, properly designed to diminish bias, are warranted.

Root caries: a periodontal perspective

BACKGROUND AND OBJECTIVE

A prevailing dental problem in the periodontal patient is root caries. Specifically, periodontal involvement often results in root surfaces becoming exposed and at risk for this condition. Periodontal therapy often leads to increased gingival recession as well, and the associated increased root caries risk may compromise the long-term success and survival of periodontally treated teeth.This narrative review will address the topic of root caries in the periodontal patient, focusing on unmet research needs.

MATERIAL AND METHODS

The Medline database was searched to identify items dealing with root caries, in terms of clinical features, diagnosis, pathogenic mechanisms and histopathology, as well as epidemiology, focusing then on the relationship between root caries and periodontal disorders.

RESULTS

Although there is extensive literature on root caries, consensus is lacking regarding certain aspects, such as diagnostic criteria, prevalence within populations and indisputable risk factors. Advancing age could be an aggravating factor in susceptibility to root caries for the periodontal patient; however, definitive evidence in this regard is still missing. Similarly, full awareness of the increased risk of root caries in patients with periodontal disease or long-term periodontal treatment appears to be still lacking.

CONCLUSION

Research regarding root caries in age-specific (elderly) periodontal patients is needed. Improved oral hygiene practices, locally applied preventive measures, good dietary habits and regular dental check-ups are crucial approaches to prevent both periodontal disease progression and root caries. Periodontal patients with root exposure should follow a strict root caries prevention protocol, as an integral component of their periodontal maintenance therapy.

Saliva and dental erosion

Dental erosion is a multifactorial condition. The consideration of chemical, biological and behavioral factors is fundamental for its prevention and therapy. Among the biological factors, saliva is one of the most important parameters in the protection against erosive wear.

OBJECTIVE

This review discusses the role of salivary factors on the development of dental erosion.

MATERIAL AND METHODS

A search was undertaken on MeDLINe website for papers from 1969 to 2010. The keywords used in the research were "saliva", "acquired pellicle", "salivary flow", "salivary buffering capacity" and "dental erosion". Inclusion of studies, data extraction and quality assessment were undertaken independently and in duplicate by two members of the review team. Disagreements were solved by discussion and consensus or by a third party.

RESULTS

Several characteristics and properties of saliva play an important role in dental erosion. Salivary clearance gradually eliminates the acids through swallowing and saliva presents buffering capacity causing neutralization and buffering of dietary acids. Salivary flow allows dilution of the acids. In addition, saliva is supersaturated with respect to tooth mineral, providing calcium, phosphate and fluoride necessary for remineralization after an erosive challenge. Furthermore, many proteins present in saliva and acquired pellicle play an important role in dental erosion.

CONCLUSIONS

Saliva is the most important biological factor affecting the progression of dental erosion. Knowledge of its components and properties involved in this protective role can drive the development of preventive measures targeting to enhance its known beneficial effects.

Is dental erosion really a problem?

Dental erosion is the non-carious dental substance loss induced by direct impact of exogenous or endogenous acids. It results in a loss of dental hard tissue, which can be serious in some groups, such as those with eating disorders, in patients with gastroesophageal reflux disease, and also in persons consuming high amounts of acidic drinks and foodstuffs. For these persons, erosion can impair their well-being, due to changes in appearance and/or loss of function of the teeth, e.g., the occurrence of hypersensitivity of teeth if the dentin is exposed. If erosion reaches an advanced stage, time- and money-consuming therapies may be necessary. The therapy, in turn, poses a challenge for the dentist, particularly if the defects are diagnosed at an advanced stage. While initial and moderate defects can mostly be treated non- or minimally invasively, severe defects often require complex therapeutic strategies, which often entail extensive loss of dental hard tissue due to preparatory measures. A major goal should therefore be to diagnose dental erosion at an early stage, to avoid functional and esthetic impairments as well as pain sensations and to ensure longevity of the dentition.

Estimated erosive potential depends on exposure time

OBJECTIVES

Evaluate erosive potential of beverages, using exposure times from 3 to 30 min, and to analyse the relationship between erosion and several drink parameters.

METHODS

pH, calcium, phosphate and fluoride concentration, saturation, titratable-acidity to pH 5.5 and the viscosity of sixteen beverages were measured or calculated. Enamel samples (N = 90) were serially exposed to 1 ml of the beverages for 3, 6, 9, 15 and 30 min and erosion was measured as the loss of calcium to the beverage. Rate of erosion per min was calculated by linear curve fitting using all exposure times. Linear regression analysis was performed to determine the correlation between erosion and the drink parameters. A limited multivariate analysis was performed for the outcome parameter with the highest univariate correlations (erosion per minute) and 4 drink variables.

RESULTS

A negative relationship was observed only for pH for all exposure times. Only for erosion per min a significant relationship with pH and saturation was found. In a model for erosion per min using only saturation, fluoride concentration, titratable acidity and viscosity, both saturation and viscosity were shown to have a significant effect (p = 0.01 and p = 0.05, respectively).

CONCLUSION

Exposure times between 3 and 30 min result in very different estimates of erosive potential. There is no sound theoretical ground for preferring one or other exposure time/outcome as being more clinically relevant.

CLINICAL RELEVANCE

This study shows that effect of the choice of study methodology on the measurement of erosive potential of beverages is large.

Erosive potential of different types of grape juices

The purpose of the present study was to evaluate the erosive potential of different types (concentrated and powdered) and commercial brands of industrialised grape juices. The pH of all five fruit drinks was measured at two time points: immediately after preparation and 24 hours later. Sixty specimens of bovine enamel were randomly allocated and immersed in different types of grape juice (n = 10) for 10 minutes four times a day for fifteen days. The enamel alteration was analysed using surface Knoop microhardness (KHN) and surface roughness (Ra) tests at baseline and on the 5(th), 10(th) and 15(th) days of the experiment. Two way ANOVA, Tukey's post hoc and Pearson's correlation tests were used for statistical analysis (α = 5%). The grape juices presented pH values ranging from 2.9 to 3.5. All of the tested juices promoted significant enamel mineral loss (p < 0.05) on the first evaluation (5(th) day of immersion) and produced a significant increase in the mean roughness from the 10(th) day on when compared to the control group (p < 0.05). By the 15(th) day, all of the beverages had produced surface roughnesses that were significantly higher than that of the control group. The results suggest that all grape juices, regardless of their commercial presentation, present erosive potential.

Counteractive effect of antacid suspensions on intrinsic dental erosion

This in vitro study aimed to investigate the anti-erosive effect of antacid suspensions applied to enamel after exposure to hydrochloric acid (HCl). Ninety bovine enamel slabs were embedded, flattened, and polished. Reference areas were created and specimens were divided into six groups. They were exposed to 0.01 M HCl (pH 2) for 2 min, followed by immersion for 1 min in one of the following test suspensions: magnesium hydroxide, aluminum hydroxide, magnesium hydroxide/aluminum hydroxide, sodium alginate/sodium bicarbonate/calcium carbonate, or hydrated magnesium aluminate. Artificial saliva was used as a negative control. Specimens were subjected to a total of five cycles of erosion/antacid treatment. Enamel surface loss was measured (in micrometers) by optical profilometry. In addition, baseline and final surface microhardness (SMH) values of enamel were obtained. It was found that antacid suspensions significantly reduced enamel loss, and that similar protection was afforded by all formulations. No differences were observed between the final enamel SMH values among groups. Antacid suspensions counteracted HCl-induced enamel loss, although they were not effective in reducing enamel softening. Mouth rinsing with antacid suspensions after vomiting can potentially represent a promising strategy to counteract enamel loss caused by erosion.

Dental erosion prevalence and associated risk indicators among preschool children in Athens, Greece

OBJECTIVES

The aims of the study were to investigate dental erosion prevalence, distribution and severity in Greek preschool children attending public kindergartens in the prefecture of Attica, Greece and to determine the effect of dental caries, oral hygiene level, socio-economic factors, dental behavior, erosion related medication and chronic illness.

MATERIAL AND METHODS

A random and stratified sample of 605 Greek preschool children was clinically examined for dental erosion using the Basic Erosive Wear Examination Index (ΒΕWE). Dental caries (dmfs) and Simplified Debris Index were also recorded. The data concerning possible risk indicators were derived by a questionnaire. Zero-inflated Poisson regression was generated to test the predictive effects of the independent variables on dental erosion.

RESULTS

The prevalence of dental erosion was 78.8 %, and the mean and SE of BEWE index was 3.64 ± 0.15. High monthly family income was positively related to ΒΕWE cumulative scores [RR = 1.204 (1.016-1.427)], while high maternal education level [RR = 0.872 (0.771-0.986)] and poor oral hygiene level [DI-s, RR = 0.584 (0.450-0.756)] showed a negative association.

CONCLUSIONS

Dental erosion is a common oral disease in Greek preschool children in Attica, related to oral hygiene and socio-economic factors.

CLINICAL RELEVANCE

Programs aimed at erosion prevention should begin at an early age for all children.

Application of the specular and diffuse reflection analysis for in vitro diagnostics of dental erosion: correlation with enamel softening, roughness, and calcium release

We present assembly and application of an optical reflectometer for the analysis of dental erosion. The erosive procedure involved acid-induced softening and initial substance loss phases, which are considered to be difficult for visual diagnosis in a clinic. Change of the specular reflection signal showed the highest sensitivity for the detection of the early softening phase of erosion among tested methods. The exponential decrease of the specular reflection intensity with erosive duration was compared to the increase of enamel roughness. Surface roughness was measured by optical analysis, and the observed tendency was correlated with scanning electron microscopy images of eroded enamel. A high correlation between specular reflection intensity and measurement of enamel softening (r(2) ≥ -0.86) as well as calcium release (r(2) ≥ -0.86) was found during erosion progression. Measurement of diffuse reflection revealed higher tooth-to-tooth deviation in contrast to the analysis of specular reflection intensity and lower correlation with other applied methods (r(2) = 0.42-0.48). The proposed optical method allows simple and fast surface analysis and could be used for further optimization and construction of the first noncontact and cost-effective diagnostic tool for early erosion assessment in vivo.

Clinical studies of dental erosion and erosive wear

We define erosion as a partial demineralisation of enamel or dentine by intrinsic or extrinsic acids and erosive tooth wear as the accelerated loss of dental hard tissue through the combined effect of erosion and mechanical wear (abrasion and attrition) on the tooth surface. Most experts believe that during the last decade there has been a significant increase in the prevalence and severity of erosive tooth wear, particularly in adolescents. Even when erosive wear occurs in its milder forms, this is a matter of concern, as it may compromise the integrity of an otherwise healthy dentition in later life. The erosive wear process is complicated and modified by many chemical, behavioural and associated processes in the mouth. If interventions are to be developed it is therefore important that in vivo methods are developed to assess the outcomes of the erosion and erosive wear processes and the effects of interventions upon them. This paper discusses potential methods of investigating erosion and erosive wear in vivo and the difficulties associated with clinical studies.

Development of an orange juice surrogate for the study of dental erosion

The aim of this study was to create a synthetic juice (SJ) to be used as a surrogate for natural orange juices in erosion studies, verifying its erosive potential. The SJ was formulated based on the chemical composition of orange juices from different locations. Forty enamel and 40 root dentin specimens were randomly assigned into 4 experimental groups (n=10): SJ; 1% Citric Acid (CA); Minute Maid Original® (MM) and Florida Natural Original® (FN). The specimens were immersed in their respective solutions for 5 min, 6x/day for 5 days, in an erosion-remineralization cycling model. Enamel specimens were analyzed by surface Knoop microhardness and optical profilometry and dentin specimens only by optical profilometry. Outcomes were analyzed statistically by ANOVA followed by Tukey’s test considering a significance level of 5%. For enamel, the surface loss and microhardness changes found for MM and SJ groups were similar (p>0.05) and significantly lower (p<0.01) than those found in the CA group. For dentin, CA promoted significantly greater (p<0.01) surface loss compared with all the other groups. No significant difference (p>0.05) was observed in dentin surface loss between MM and SJ. In conclusion, CA was the most erosive solution, and SJ had a similar erosive potential to that of MM natural orange juice.