Dental erosion involves the demineralization of dental hard tissue caused by acids not of bacterial origin, softening of tooth structure and erosive wear. According to the American Dental Association (ADA), common signs of dental erosion include loss of enamel texture, a silky, glossy or “melted” appearance of the enamel, ‘chipped’ and thin incisal edges, and altered occlusal morphology with flattened or cupped surfaces. Other signs may include wide concavities present on smooth surface enamel, translucency, ‘raised’ amalgam restorations, and exposure of dentin once the enamel has been lost. Affected teeth may also look chalky, pitted, or yellow.
Acids of nonbacterial origin
Acids of nonbacterial origin include those that are intrinsic (gastric acid originating inside the body) or extrinsic where the acid originates externally. Diet is a leading source of extrinsic acids that cause dental erosion. This article offers guidance for dental hygienists on how to uncover, discuss and manage dietary causes of dental erosion in their patients.
Dietary causes of erosion
When acidic foods or drinks are consumed, the pH of the oral cavity becomes more acidic. Salivary flow increases during eating and drinking, and salivary buffering capacity works to neutralize the acidity and restore optimal oral pH. It also contains minerals that can help prevent demineralization. However, when the intensity and frequency of acid exposure exceeds the buffering and protective capabilities of saliva, dental hard tissues are irreversibly eroded and weakened.
The ADA states that there is a growing body of evidence suggesting that the primary predisposing factor for extrinsic erosion is the frequent consumption of soft drinks, sports drinks and fruit juices with low pH values of between 2.5 and 3.0. Other common dietary culprits include:
Carbonated beverages (even fizzy water and sugar-free or “diet" drinks).
Acidic foods, e.g., citrus fruits
Sour candies and sweet-sour candies
Chewable vitamin C supplements.
Coffee may indirectly contribute to dental erosion because caffeine reduces salivary flow. Dental Health points out that alcopops, coolers, and “designer drinks” often contain a double-whammy of carbonation and acidic fruit flavorings. Meanwhile, Mouth Healthy warns that even some foods perceived to be healthy, such as tomatoes and raisins, are acidic and can therefore contribute to erosion.
Asking the right questions
When it comes to gathering information on dietary causes of erosion, there are a few challenges the dental hygienist must overcome:
The patient may have limited understanding of what constitutes an “acidic” food or drink. For example, when you ask them about acid consumption, they may assume that all acidic foods and drinks are sour or tart, not thinking to disclose their chocolate or candy consumption.
The patient may not make the connection between dental erosion and perceived “healthier” foods or drinks, such as fizzy water, tomato, or fruit juice.
Therefore, it's important as a dental hygienist to ask the right questions. Begin the conversation by giving a quick 101 on erosion and explain which foods and drinks present a risk, then ask questions like:
How often would you say you enjoy coffee/wine/sodas/fruit juice/fizzy drinks?
Do you like tangy or sour foods? Which are your favorites? How often would you say you have them?
Do you like tomato-based dishes? How often do you eat them?
How many pieces of fruit would you have on a normal day? Which are your favorites?
Would you say you have a sweet tooth? How often do you eat candies, sweets or chocolates?
How often do you work out? What do you drink to stay hydrated?
What would you normally drink with a meal?
How much water do you drink throughout the day?
Do you take any chewable vitamins or other supplements, like gummies? What do you take them with?
How often would you say you snack during the day? What do you usually reach for?
Do you prefer creamy or tangy salad dressings? How often do you have them?
Would you say your dietary habits stay consistent all week, or are there some things you enjoy more at the weekends?
When it comes to what we perceive as “bad habits”, we humans tend to have a tendency to underestimate our behaviors. Your patient might do this deliberately for fear of judgment, or unintentionally through simple unreliable recollection.
To avoid the former, it is important that we respect our position as partners in the patient’s oral care. That means creating a judgment-free space for the patient to be honest about their dietary habits, and refraining from anything that can be perceived as critical and telling them off/scolding. Explain that there are lots of hidden causes of erosion that can trip us up, but that you’d like to share what you know and help them to figure out if there are any contributing factors you can offer advice on. Emphasize that it’s not about cutting out all the things we love, but more about enjoying them in a way that supports our oral health.
Managing dietary causes
In addition to educating the patient on common dietary causes of erosion, you can offer the following advice to help them manage their risk:
Reduce intake of acidic beverages like sports drinks, fruit juices, and sodas
Reduce intake of sour and sweet-sour candies
Reduce snacking on acidic foods and snacks between meals
Incorporate yogurt, cheese, or milk into meals and snacks
Drink tap or other still water or milk with acidic foods, such as tomato-based dishes.
Drink with a straw to minimize acid contact with the teeth
Avoid swishing drinks around the mouth or straining them between the teeth.
Rinse the mouth with still water after consuming acidic foods and drinks
Do not brush the teeth immediately after consuming acidic foods and drinks
Chew sugar-free non-acidic gum after eating to stimulate salivary flow
Choose capsule supplements over chewables or gummies.
For patients at increased risk, a high-level fluoride toothpaste like Colgate PreviDent 5000 Enamel Protect can offer additional protection, strengthening the enamel.