The connection between diet and enamel erosion
by Alicia Almeida, RDH; Heidi Emmerling, RDH, PhD; Lauren McGreanor, RDA, RDH; Ashley Mitchell, BA, RDH
Eat
your fruits and vegetables. Exercise. For a healthy lifestyle, these
are important rules to live by. Ironically, our patients may be doing
just that – eating their fruits and veggies and exercising the enamel
right off their teeth.
*healthtrition.com |
Enamel can be damaged by a number of
factors: caries, abrasion, abfractions, and erosion. This article will
focus on how we can better inform our patients about erosion, its
dietary causes, and the preventive measures that can be taken.
A
need certainly exists to better educate patients about enamel erosion.
Information and knowledge about surface enamel wear and its causes,
consequences, and prevention should be better understood in order for
people to achieve optimal oral health.
Informal poll findings
indicate that almost half of those surveyed did not know what enamel
erosion is. Of those who did, approximately one-third were unaware of
the cause. While almost all knew that diet played a role in enamel
health, the same number did not know that frequency was a factor. Here's
the kicker: 92% reported that neither their dentist nor dental
hygienist spoke to them about enamel erosion.
Dental hygienists
can explain to patients the difference between erosion and caries – that
enamel erosion is the irreversible wear due to enamel and dentin being
chemically etched away, and that this process, unlike caries, does not
involve bacteria. Some signs and symptoms include a smooth, shiny
surface; roundedness; cupping on occlusal surfaces; generalized loss of
luster or brightness; and a discolored and yellowish appearance.
Additionally, the teeth will frequently have increased sensitivity.
For
the patient, enamel erosion is significant. First, it causes dentinal
hypersensitivity. Also, as the enamel becomes thin, the teeth are more
susceptible to decay, and enamel erosion could lead to complex and
expensive restorative care. Therefore, patients have a vested interest
in learning about causes and preventive measures.
Xerostomia is a
factor in enamel erosion. Patients may not be aware of the protective
properties of saliva: rinsing, buffering, and remineralizing. Reviewing
the medical history for causes of xerostomia, as well as asking the
patient about a history of dry mouth, gives the dental hygienist the
opportunity to discuss the role of saliva and diet in erosion. Another
thing to keep in mind is that saliva is more protective of enamel than
dentin. Consequently, it is important to consult elderly people and
others with dentinal exposure that they may be at a greater risk of
dietary erosion than those with no dentinal exposure.
Other
non-nutritive sources of erosion include GERD, bulimia, and alcoholism.
In all of these cases stomach acids and vomit can enter the oral cavity,
lowering the pH of the oral cavity. Additionally, swimmers exposed to
chlorine can be at risk for erosion.
Most patients already know
that diet plays a role in many oral diseases, such as the role of sugar
in caries, for instance. They probably know that candy is bad because of
the high sugar content. However, they might not know that sour candies
are even worse. Erika Feltham, RDH, who has been passionately educating
patients and other dental professionals about the harmful effects of
sour candies explains how some candies' pH levels approach the level of
battery acid (Quick Blast™ Sour Candy Spray, Warheads® Extreme Sours).
Candies use ascorbic, acetic, adipic, citric, fumaric, lactic, malic,
and tartaric acids to achieve the sour flavor. Sneaky labeling might
conceal these acids: natural or artificial flavors, organic fruit juice
extracts, and juice paste. Some of these sour candies not only contain a
variety of acids, but are also coated in acid by using processes called powder acid blending, dusting, or encapsulated acid techniques.
Similarly,
patients might have a hunch that soda pop is bad for oral health
because it is loaded with sugar. However, dental hygienists can explain
that, in addition to the very high fructose content, sodas are also
acidic. Therefore, even diet sodas can wreak havoc on the enamel.
Additionally, patients should be informed about the sugar and acid
content of many sports drinks. Many patients might be misled thinking
that sports drinks are healthy and have no consequences.
Because
pH is such a critical factor in dietary enamel erosion, dental
hygienists can give patients brief lessons in pH 101: Under normal
conditions, the pH in the mouth ranges from 6.2 to 7.0. Enamel
demineralization occurs when pH levels fall to 5.7. Elderly patients or
those with exposed dentin need to know that root demineralization can
occur when pH levels fall to 6.0. After consuming an acidic meal or
snack, pH levels are likely to drop to these ranges, increasing the
potential for erosion.
But what constitutes an acidic meal?
Patients probably know that sucking on lemons is acidic, but they think
nothing of consuming concentrated citric fruit juices. And there are
other foods people often don't think of as acidic such as yogurt and
applesauce. Almeida, McGreanor, and Mitchell wanted to see if erosion
would occur with normal foods in the absence of plaque and if there was a
correlation between erosion and the pH level. They took 12 extracted
teeth and submerged them into 12 foods of variable pH ranges for two
weeks (see Photo 1). The teeth were kept in airtight containers and were
refrigerated at 37° F to prevent any bacterial growth. Sugar content
was not thought to factor in to the results, as no plaque was present on
the teeth to metabolize the sugar into acid end products. The foods
were changed and pH levels checked every three days. See Table 1 for the
foods, pH levels, and appearance of the teeth after the experiment.
The
teeth soaked in the more acidic pH ranges (applesauce, oatmeal) were
discolored, more yellow, and appeared very shiny and smooth; they
appeared very different from their photos taken before the experiment.
The teeth with the more neutral/alkaline pH (fudge brownie, avocado,
butter) showed less effects of erosion and had fewer changes from their
photos before the experiment. The control tooth showed no changes from
before to after the experiment.
Patients may not know that foods we think of as healthy for our
bodies may not be beneficial for our oral health. A healthy lifestyle
indeed implies the consumption of food and beverages predominantly of
vegetable origin which are usually acidic. Citric fruit juice (with a pH
value of approximately 3.2), fruits in general, and vegetables are
essential in a diet, but consumed in excess they have enough potential
to cause erosion. Healthy lifestyles also imply physical exercise, which
in excess also has great erosion potential since it increases GERD.
Besides, if we add the loss of body fluids, the decrease in salivary
flow that this exercise generates can either cause xerostomia and/or
increase the consumption of sports drinks (whose general pH values are
between 2.7 and 3.1). This is the best possible medium for generating
acid erosion. Dental hygienists can encourage patients to think about
the acids in sports drinks, concentrated fruit juices, and acidic fruits
such as lemons and oranges. Hygienists can explain how typically
healthy foods like applesauce and yogurt can lead to enamel erosion.
In
addition to dietary recommendations, it is important to let patients
know how to prevent enamel erosion from occurring. Here are some
recommendations for patients to put tooth enamel to good use – to eat
food, not the other way around:
- Drink water throughout the day.
- Never brush the teeth after consuming acidic foods or beverages as the teeth are weak and time should be given for remineralization.
- After eating or drinking something highly acidic, rinse with water or fluoride to neutralize the acid.
- Use sugar-free gum to stimulate salivary flow.
- Use a straw when drinking acidic drinks to avoid contact with the teeth.
- Use a fluoride toothpaste to strengthen the teeth and stimulate remineralization.
- Reduce consumption of acidic foods and beverages.
- Snacking on low-pH foods frequently throughout the day means there are more opportunities for demineralization and less opportunities for remineralization.
Reviewing dietary and lifestyle factors
that influence oral health are important. The types of foods and
beverages consumed, individual susceptibility, the frequency and times
of consumption, and oral hygiene practices are important factors
influencing the clinical development of dental erosion.
Article from: RDHMag, Vol. 30 - Issue 9
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