Clinical guidelines for dental erosion

Diagnosis, prevention and management of dental erosion

2021
 Clinical guidelines for dental erosion

Contents
Introduction3
Intended audience 4
Statement of conflict of interest 4
Aims and objectives 4
Development and evidence base 4
Prevalence 5
Aetiology 7
Intrinsic acidic sources 8
Extrinsic acidic sources 10
Presentation and diagnosis  13
Management: preventative treatment 14
Patient information leaflets 14
Recording and monitoring erosion 14
Dietary analysis 15
Dietary counselling 16
GORD, vomiting and rumination 16
Oral hygiene, remineralisation and desensitisation 17
Other/novel preventative strategies 18
Management: restorative treatment 19
Primary dentition 19
Mixed dentition 19
Permanent dentition 20
References 24

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Clinical guidelines for dental erosion

Lead Coordinator

Elizabeth O’Sullivan
Consultant in Paediatric Dentistry, City Health Care Partnership, Hull

Contributors

Ishpinder Toor
Consultant in Restorative Dentistry, Guy’s and St Thomas’ NHS Foundation Trust, London

Lucy Brown
Consultant in Paediatric Dentistry, Harrogate District Foundation Trust

Sophie Watkins
Consultant in Restorative Dentistry, Guy’s and St Thomas’ NHS Foundation Trust, London

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 Clinical guidelines for dental erosion

Introduction

Toothwear is recognised as a major dental problem in both children and adults. The triad of
erosion, attrition and abrasion has been known for many years, and the contribution of erosion to
toothwear is increasing.1 Dental erosion is the irreversible softening and subsequent loss of dental
hard tissue due to a chemical process of acid dissolution but not involving bacterial plaque acid,
and not directly associated with mechanical or traumatic factors, or with dental caries. Attrition
may be defined as direct tooth-to-tooth contact wear while external foreign agents moving across
and contacting the tooth surface results in abrasion. Erosion usually coexists with attrition and/
or abrasion but one of these factors may be more significant than the others, making differential
diagnosis difficult.

Erosive wear is now deemed a common global phenomenon of developed countries,2 and
its financial burden on patients and public health services is significant.3 More importantly,
the morbidity associated with erosive wear may be high, and can include pain/sensitivity,
dissatisfaction with aesthetics and reduced function. While the ultimate causative factors of dental
erosion are non-bacterial acids, it is a multifactorial condition, and the progression of the lesions
are driven by a complex interplay between nutritional and patient related factors.

Owing to its progressive nature, preventative measures implemented (ideally, in the early stages
of erosive wear) can be effective in reducing the need for dental intervention and symptoms
experienced by patients. Operative measures will still be necessary for those with advanced
erosion progression in order to eliminate pain, and to restore function and aesthetics. Additionally,
interventive treatment may be warranted to preserve the structural integrity of the reduced and
remaining tooth structure, and to protect against further tissue loss.

This guideline aims to assist the dentist to diagnose, prevent and manage erosion in children,
adolescents and adults. This may be complex, and can require interdisciplinary long-term
management and liaison with medical colleagues.

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Clinical guidelines for dental erosion

Intended audience

This guideline provides information for the whole dental team who are involved in the
diagnosis, prevention and management of dental erosion. It would also be useful for other
healthcare providers who give dietary advice to patients. It is intended that by using the
guideline informed and evidence-based discussions can be carried out with patients.

Statement of conflict of interest

The Faculty of Dental Surgery is funded by its fellows and members, and no contributors or
reviewers were paid for their work on this guideline.

Aims and Objectives

The aims and objectives of this guideline are to describe and explain the diagnosis, prevention
and management of dental erosion in children and adults using evidenced based literature, so
that clear information and discussions can be carried out with patients and carers.

Development and evidence base

This guideline was developed from existing guidelines by a small working group with members
from the specialties of Paediatric Dentistry and Restorative Dentistry and the final draft
was approved by each specialist societies clinical effectiveness group. At the beginning of
development of the guideline the evidence base was established by each member carrying out
a rapid review of the literature to optimise the use of the most current and relevant literature.
The guideline development group employed a modified Delphi methodology (the guideline draft
is circulated to the group, feedback is collated, before another draft is produced and circulated
again for appraisal. In order for a recommendation to be included in the final guideline at least
90% of the working group were required to provide approval. Other stakeholders were then
involved including the Dental Faculty RCS England Guideline Committee and the Delivering
Better Oral Health Working Group. Final approval was sought from the British Society of
Paediatric Dentistry and the British Society of Restorative Dentistry.

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 Clinical guidelines for dental erosion

Prevalence

Epidemiological studies over the past 20 years both in the UK and abroad have highlighted the
prevalence for dental erosion.2,4,5 In recent reviews on the global prevalence of erosive wear, it
has been deemed a common phenomenon of the general population of developed countries,
with a mean prevalence in deciduous teeth of between 30% and 50%, and in permanent teeth
of between 20% and 45%.2,6 Such wide variation in global prevalence rates is a reflection of
the heterogeneity of erosive toothwear studies. This heterogeneity relates to factors such as
differences in the toothwear indices used, sample size, study populations chosen and lack of
standardisation in the quantification of dimensions of tissue loss.

Prevalence data from cross-sectional UK studies indicate that dental erosion increases
between different age cohorts of young people over time (Table 1).7–20 Prevalence of overall
toothwear in dentate English adults increased from 66% to 76% between 1998 and 2008;
moderate wear that has exposed a large area of dentine on any surface also increased from
11% (1998) to 15% (2009).21 This increase, however, is not uniform across age groups, with the
greatest increases in adults seen in the younger age groups. A systematic review reportedthat
the prevalence of toothwear in adults increases with age.22 While data could not indicate
whether this increase simply reflected the aging process, it is probable that the increase in
moderate toothwear is small in surveys conducted in England. Wear in younger adults is likely
to be important clinically and is suggestive of more rapid toothwear attributable to factors other
than age.

Sex differences in the prevalence of toothwear are not clearly confirmed in the literature. Some
studies have observed no association with sex, with others reporting a higher prevalence in
one of the sexes. Overall, where a sex association has been found, the majority of studies
favour an increased prevalence seen in male patients.2

Primary teeth have been shown to be more prone to erosive toothwear, which occurs more
rapidly than in the permanent dentition,23 with the prevalence and severity of erosive toothwear
increasing in the preschool population.24 Those patients who exhibit signs of erosive toothwear
in the primary dentition have been shown to have an increased prevalence of erosion in the
permanent dentition.25

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Clinical guidelines for dental erosion

Table 1 Prevalence studies

Author Year of Age Sample size % with dentine % with palatal / Teeth Surfaces
publication* exposed occlusal / labial
dentine exposed
O’Brien7 1994 5 years Total 17,061 24% 24% U1” incisors
12/14 years 2% 2% U2” incisors

Millward8 1994 4 years 178 48% All 1” teeth All

Milosevic 9
1994 14 years 1,035 30% 8% 8% All 2” teeth
Jones10 1995 3 years 135 17% U1” incisors Labial/palatal
Hinds11 1995 1½–4½ years 1,496 8% U1” incisors Labial/palatal
Smith 12
1996 <26–>65 years 1,007 26% with extensive All 2” teeth All
toothwear
Bartlett13 1998 11–14 years 210 2% All 2” teeth All
Williams14 1999 14 years 525 11% 1% U2” incisors Labial/palatal
Walker15 2000 4–6 years 363 19% U1” or 2” incisors Labial/palatal
7–10 years 500 18% First 1” or 2” Occlusal
11–14 years 518 3% molars

15–18 years 345 5%

Al-Dlaigan16 2001 14 years 418 52% All 2” teeth All
Bardsley 17
2004 14 years 2,351 53% 10% All 12 anterior Labial, incisal,
teeth palatal/lingual
First molars Occlusal
Chadwick 18
2004 5 years Total 12,698 22% U1” incisors Labial/palata
12/15 years U2” incisors Labial/palata

Dugmore19 2004 12 years 1,753 3% Incisors and Labial/palatal

first molars Buccal/occlusal/
lingual

Pitts2 2015 5 years 2,549 16%/4% U1” incisors Lingual/buccal

12 years 2,532 2%/– U2” incisors Lingual/buccal
12 years 2,532 1% First 2” molars Occlusal
15 years 2,418 4%/1% U2” incisors Lingual/buccal
15 year 2,418 3% First 2” molars Occlusal

*not year survey conducted

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 Clinical guidelines for dental erosion

Aetiology

Dental erosion involves the softening of the tooth surface by acidic substances of intrinsic
or extrinsic origin, or a combination of both.26 Repeated and prolonged contacts with acidic
substances not only cause softening of the tooth surface but can also lead to overall loss of
tooth structure.6

The softened tooth structure is further left susceptible to mechanical impact.27 Erosion,
therefore, rarely has an isolated effect on toothwear but interacts with other wear mechanisms
(abrasion, attrition) to potentiate their effect.28,29 The combination of chemical-mechanical tooth
surface loss caused by the processes of dental erosion followed by abrasive and/or attritive
wear is referred to as erosive toothwear.6,26 This term highlights the co-action between the three
commonly recognised toothwear processes.

As stated, the principal aetiological agents of erosive wear are intrinsic and extrinsic
non-bacterial acids. Ideally, the source of the acidic substances should be identified prior
to patient management. This is not always possible because of the difficulty in gaining an
accurate and contemporaneous relevant history or because the patient may withhold important
information regarding lifestyle or behaviour. Nevertheless, the identification and reduction of
risk factors will improve the success of management. It is consequently important to question
each patient about their medical history, medication, dietary content and habits, lifestyle and
occupation.

The dietary intake of acidic foodstuffs may be quite high in certain cases, and careful
questioning on the intake of specific items of food and drink is necessary (Table 2). Dietary
associations with erosion are present but weak. Future research may establish causal
relationships and the influence of co-factors in the erosive process. In vitro studies have
identified dietary factors with erosive potential but further research is needed to fully
understand causal relationships and co-factors such as risky behaviours that increase
the risk of erosion.

Table 2 Dietary items with erosive potential

Beverages
• Carbonated or fizzy drinks excluding ordinary unflavoured sparkling water
• Pure fruit juice, smoothies and cordials
• Certain alcoholic drinks (eg cider, white wine)
• Herbal teas
Foods
• Fruits (especially citrus, grapes, sour apples)
• Sauces (eg ketchup, brown sauce)
• Snack foods (eg salt and vinegar crisps)
• Vinegar and pickled foods

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Clinical guidelines for dental erosion

In vitro studies show promise with respect to modification of drinks to reduce erosive
potential.30,31 Continuing acid exposure not only results in a clinically detectable defect but also
softens the tooth surface, making it more prone to mechanical impact. The primary causative
factor is not always apparent; however, it is clear, for example, that while enamel is scarcely
abraded by normal toothbrushing, it is rendered more susceptible to wear following an acid
challenge.27

Intrinsic acidic sources

The singular source of intrinsic acid related to dental erosion is gastric juice. Gastric acid may
enter the mouth secondary to gastro-oesophageal reflux, vomiting or rumination and can lead
to significant palatal erosion.

Gastro-oesophageal reflux disease

Reflux is the passive or effortless movement of regurgitated acid into the mouth and when
this occurs regularly over a prolonged period, it is referred to as gastro-oesophageal reflux
disease (GORD). It is this more persistent form of reflux that may lead to pathological dental
erosion. GORD is considered relatively prevalent and in a 2014 systematic review, between
8.8% and 25.9% of adults in Europe were reported to be affected by this condition.32 The
causes of GORD are summarised in Table 3.

Table 3 Principal causes of gastro-oesophageal reflux

Sphincter incompetence
• Oesophagitis
• Alcohol
• Hiatus hernia
• Pregnancy
• Diet (eg spicy/fatty foods)
• Drugs (eg diazepam)
• Neuromuscular (eg cerebral palsy)
Increased gastric pressure
• Obesity
• Pregnancy
• Ascites
Increased gastric volume
• After meals
• Obstruction
• Spasm

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 Clinical guidelines for dental erosion

Signs and symptoms associated with reflux comprise heartburn, retrosternal discomfort,
epigastric pain and hoarseness or asthma-like symptoms although symptoms are not reliable
indicators of the presence or absence of GORD. Patients may be symptom free despite
continuation of reflux. These patients are described as ‘silent refluxers’ and can remain
undiagnosed.

GORD is known to cause dental erosion and should always be considered a possible cause
in the presence of indigestion, heartburn or epigastric pain.33,34 Extra-oesophageal symptoms
(including dental erosion, chronic cough, asthma and laryngitis) have significant correlations
with GORD.35 Furthermore, reflux disease patients with frequent respiratory symptoms appear
to have a greater prevalence of dental erosion than those without reflux associated respiratory
disorders.36 Clinicians should be mindful, however, that nearly 25% of adult patients presenting
with extensive palatal erosion had pathological GORD diagnosed by standard criteria but did
not have any symptoms of reflux.33 In silent reflux, dental erosion may therefore be the only
clinical sign that reflux is occurring.

Dental erosion in relation to GORD is less of a problem in children. This may be due to a
shorter history of GORD or because refluxing is limited to the oesophagus.37 The exception
is seen in neurologically impaired children, where significantly higher levels of gastric reflux
are seen compared with healthy children, with over 70% of children with cerebral palsy having
abnormal reflux activity.38–40

Vomiting
Vomiting involves a host of physiological events, coordinated in the medulla, resulting in the
forceful propulsion of stomach and upper intestinal contents towards the mouth. Vomiting may
be spontaneous or self-induced and is often associated with an underlying medical condition.
Spontaneous or self-induced vomiting needs to be persistent for dental erosion to occur, and
the medical conditions associated most frequently with persistent vomiting include eating
disorders, pregnancy, alcoholism and cyclic vomiting syndrome.41

Eating disorders can be divided into anorexia nervosa, bulimia nervosa, self-induced vomiting
and eating disorders not otherwise specified.2 The prevalence of eating disorders in England
in those aged 16 years and older is estimated at 7.8% and the disorder typically develops in
younger females in their late teens to mid-twenties.42 Traditionally, it has been considered that
teenage girls are particularly prone to abnormal eating behaviours; nevertheless, the number
of affected males is felt to be underrepresented in the literature.43 Self-induced vomiting is a
common feature of the eating disorders of anorexia and especially bulimia nervosa. Athletes
including professional jockeys have also been reported to engage in this habit. Patients who
self-induce vomiting have been shown to have higher risk of tooth erosion than peers who do
not vomit.44

Eating disorders associated with vomiting are associated with an increased occurrence,
severity and risk of dental erosion.² Interestingly, the frequency, duration and total number
of self-induced vomiting episodes in those with eating disorders are not seen to be linearly
associated with the severity or number of eroded teeth, indicating that other factors are at play.

Spontaneous vomiting may occur frequently during the first trimester of pregnancy.

Seen in children, cyclic vomiting syndrome is recognised to be linked with irritable bowel
syndrome, motion sickness, migraine and epilepsy.41 Prolonged bouts (weeks) of vomiting can
begin in preschool children, occur throughout child development and reduce in frequency by
adulthood. The condition is therefore self-limiting.

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Clinical guidelines for dental erosion

Alcohol dependence may be associated with both regular vomiting and reflux, significantly
increasing the risk for dental erosion. There is conflicting evidence in the literature regarding
the relationship between alcohol dependence and erosive defects. However, a trend for both
increased severity and prevalence of erosion is broadly seen in those with chronic alcoholism.45

Rumination
The ability to relax the lower oesophageal sphincter, reflux gastric contents into the mouth and
re-swallow is uncommon but has been reported.46 This naturally poses a risk for dental erosion.

Extrinsic acidic sources

There are multiple exogenous acids that have been discussed in relation to dental erosion.
These can be categorised into those from dietary, pharmacological and environmental/lifestyle
sources.

Dietary extrinsic acids

An acidic diet is widely associated with dental erosion, and careful questioning on the intake of
specific items of food and drink is necessary (Table 2). A low pH and a high buffer capacity (the
resistance of a dietary product to being neutralised by saliva) are deemed the major risk factors
for erosive potential, with the calcium concentration in foods and drinks regarded as the major
protective factor.26 It is important to consider all these factors together in understanding the
erosive potential of foods and drinks. For instance, yoghurt has a low pH of 4 but a very high
calcium concentration and therefore has a low erosive risk overall. Additionally, the consistency
as well as the content of foods and drinks are important; a consistency that increases
adherence to the tooth surface will clearly prolong the erosive challenge.

While the erosive potential of specific dietary acids is important to consider, it is also necessary
to review the overall pattern of consumption. Frequency of dietary acid intake is a primary
risk factor for erosive toothwear progression.47,48 Four or more nutritional acidic intakes per
day, in the presence of other risk factors (such as low buffering capacity of stimulated saliva
and use of a hard bristled toothbrush), is associated with higher risk for the development
and progression of erosion.49 Moreover, an increased frequency of dietary acids that are also
consumed between meals represents a further increased risk for erosive toothwear.50

The above said, it should be noted that the relationship between dietary acids and erosion is
not straightforward, with some who consume dietary acids developing erosive toothwear and
others not.47 It is accepted that this a reflection of other co-factors being highly influential (eg
salivary flow rates, buffering capacity and salivary composition). Future research is needed to
fully understand causal relationships and the influence of co-factors in the erosive process.

Drinks
Carbonated soft drinks (including their sugar free counterparts) are considered to have a high
erosive potential. Evidence linking dental erosion with soft drink consumption is available in the
literature.51 Fruit juices, including smoothies, may also have high acidity and potential for dental
erosion due to the fruit content and other additives (see Foods).

For carbonated soft drinks, fruit juices and smoothies, the risk to children and adolescents is
concerning given that consumption rates are high and increasing among this age group.6,52,53
Indeed, soft drinks have been reported to provide as much as a fifth of the added sugars in

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 Clinical guidelines for dental erosion

the diet of 11–12-year-old children, and 42% of fruit drinks are consumed by children aged
between 2 and 9 years.54 Drinks delivered from a feeding bottle, used as a comforter, may be
particularly harmful to infants, with reported extreme dental destruction resulting from abuse
of fruit juices.55 Preventative measures aimed at dietary extrinsic acids for children and young
adults are therefore a vital strategy in reducing prevalence of erosive toothwear, especially as
dietary patterns established in formative years can carry on into adulthood.

The addition of fruit (particularly slices of lemons or limes) or fruit flavourings (eg cordials) to
drinks has increased and it is safe to assume that any added fruit flavourings of this kind will
render the beverage acidic.47

Fruit flavoured teas such as ginger and lemon, berry and rosehip are also considered
acidic.47,56 There is some evidence that warming beverages may increase their erosive
potential; this may be especially relevant to the consumption of fruit flavoured teas and hot
cordials.57

Sports drinks are also considered to have a high erosive potential and are increasingly
consumed owing to the promotion of active, healthy lifestyles.

Some alcoholic drinks, such as dry wine, cider and alcopops, are also acidic.58–60 Alcohol
consumption, as mentioned, is also linked with gastric reflux, and may consequently be both an
intrinsic and extrinsic agent of erosion.61

As a general rule when simplifying the message for patients, most drinks that are not water,
plain carbonated mineral water (sparkling water) or milk are acidic.47 Beverages with erosive
potential are listed in Table 2.

Part of the erosive potential of a given beverage is also the manner in which it is consumed.
In a recent study, participants who admitted to constant sipping, swishing, swilling or holding
the drinks in the mouth prior to swallowing had approximately ten times increased odds of
developing erosive toothwear.50 This finding has been confirmed in other studies. Where
advanced erosive toothwear is present in someone with seemingly limited acid exposure, the
presence of a habit that increases the duration of contact between the acidic component and
the tooth surface should be considered.

Calcium and/or phosphate compounds have been added to beverages to test their effect in
reducing the erosive potential. In vitro studies show promise with respect to modification of
drinks to reduce erosive potential.30,31

Foods
Fresh fruit and in particular citrus fruit62 have erosive potential, as do chillies and tomatoes.47
Foods pickled in vinegar and vinegars can be highly acidic; their consumption may be
prevalent in certain international diets and are being increasingly promoted as part of a healthy
diet. Less well known is the influence of covert acids in foodstuffs that have been associated
with erosion in teenagers (eg brown sauce, crisps, ketchup and vinaigrette).63 Flavoured
(acid-based, sugar containing) chewing gums are also considered to have potential for dental
erosion. Foods with erosive potential are listed in Table 2.

Lifestyle changes have undoubtedly increased the acidity content of modern diets. A greater
emphasis on a healthy diet has resulted in an increase in fruit and vegetable consumption for

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Clinical guidelines for dental erosion

some individuals. National campaigns for healthy eating have also emphasised the importance
of eating at least five portions of fresh fruit or vegetables per day, and the health benefits of
consuming fruit and vegetables regularly should be encouraged as part of a balanced diet.
(See the NHS Eatwell Guide – www.nhs.uk/live-well/eat-well/the-eatwell-guide.)

More people are becoming vegetarian and this tends to be a more acidic diet. However,
very few studies confirm a correlation with dental erosion and overall, the results are
contraindicatory. Lacto-vegetarians were reported to have significant dental erosion although
the study has not been repeated in order to confirm this association.64 Raw food diets, which
include consuming only non-processed foods, have been shown in a small sample study to
increase the risk of dental erosion versus consumption of a conventional diet.65

Given the importance of fruit and non-starch vegetables for general health, it is important that
people are not advised to reduce their fruit consumption since as a society, we do not consume
enough for health. Instead, only people for whom it is a clear identified risk factor should be
advised to modify their diet to perhaps swap a citrus fruit for vegetables, banana or avocado
between meals to ensure that they maintain a healthy diet and consume at least five a day.

As with acidic beverages, it is not just the total exposure to acidic foods that appears to have
increased in recent years. There have also been changes in dietary habits/patterns. The
frequency of food intake is changing; greater numbers of snacks are being consumed and long
periods of snacking are occurring, commonly known as ‘grazing’.

In a multicultural society, there will be different habits and varieties of food not necessarily
indigenous to the UK as well as different methods of food preparation. Little is known about
these influences on dental erosion. Slaking palm with lime juice, betel nut chewing and
crunching of chicken bones to savour the bone marrow have all been reported to increase
the risk of toothwear and erosion.66 Although not usual among Western cultures, these habits
will be common among people from other cultures who live in the Western world. Clinicians
should be aware of these cultural differences and question patients about any habits that may
increase the risk of wear.

Pharmacological extrinsic acids

A number of medications and dietary supplements (such as vitamin C, aspirin and some iron
preparations) are acidic and potentially erosive if they are in the form of chewable tablets or
effervescent drinks.26,67 It is unlikely, however, that these are in widespread use among children
and adult population groups. Asthma medications have been speculated to increase dental
erosion but the results are inconclusive.68,69

Many medications or medical treatments induce a dry mouth (eg antihistamines, anti-
emetics, antidepressants, anti-Parkinson, diuretic medications, and head and neck targetted
radiotherapy). The increased risk of erosion in these patients occurs because of the loss
of salivary protective factors with reduced salivary flow. Furthermore, xerostomic patients
may have a tendency to suck acidic sweets to alleviate their symptoms, which can further
compound their risk of erosion. Some medications induce nausea and vomiting. The potential
comorbidities of dry mouth and vomiting caused by some medications on dental erosion has
not been investigated widely.

Destruction of dental hard tissue can be found in drug dependent persons. Nevertheless,
attritional toothwear is seen more commonly than erosive toothwear owing to drug induced
muscle hyperactivity.70

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 Clinical guidelines for dental erosion

Lifestyle/occupational extrinsic acids

Active lifestyles and leisure trends can be associated with a greater risk of erosion,71,72 and in
a systematic review of the oral health of elite athletes, prevalence values for dental erosion
of between 36% and 85% were recorded.73 Professional athletes and swimmers are reported
to be at increased risk of dental erosion due to exposure to sports drinks and swimming pool
water. Well buffered, pH controlled chlorinated swimming pools, however, mitigate the risk of
dental erosion and highly frequent swimming activities are therefore considered an uncommon
risk factor for erosion.2

Work related exposure to acids in the form of liquids or vapours can result in dental erosion.74
Wine tasters, battery manufacture workers, and those working in galvanising and plating
factories may be considered at increased risk for dental erosion. This is generally considered
a rare cause of erosive toothwear and most industries have to adhere to occupational health
legislations limiting exposure.26,71,74–76

The use of mood enhancing drugs such as ecstasy increases the risk of dental erosion/
toothwear.70,77–79

Presentation and diagnosis

A diagnosis of erosive wear should be made as early as possible so that preventative

strategies may be implemented quickly to limit further progression. Careful examination should
consequently take place under good lighting with dry teeth to facilitate recognition of even the
subtlest signs of dental erosion.

In general, erosive toothwear is characterised by the loss of tooth surface morphology and
contour. Few studies have investigated the site specificity of dental erosion but the literature
indicates that the palatal and labial aspects of maxillary teeth and occlusal surfaces of the
mandibular teeth are commonly affected.80 It is further reported that extrinsic acids contributing
to dental erosion will predominantly affect the buccal cervical surfaces of the maxillary teeth
and the occlusal surfaces of the mandibular posterior dentition. In cases of dental erosion
caused by intrinsic acids, toothwear affects the palatal surfaces of the maxillary dentition, with
protection of the lower anterior lingual surfaces by the tongue.81

On the occlusal surface, cusp tips may be cupped with flattening of occlusal contours and a
less defined groove–fossa system may be observed. In advanced stages, the entire occlusal
morphology may disappear with the presence of hollows, concavities and exposed areas of
dentine. Concavities are typically wider than they are deep. Restorations may stand proud of
the adjacent occlusal surface. Incisally, edges may become grooved or chipped and increased
translucency may be seen, resulting in a bluish appearance. Exposure of dentine increases as
erosion progresses.

On smooth surfaces, there is flattening of the entire surface. Loss of the perikymata and
cingulum may also be noted. As enamel becomes thinner, chamfered ridges or ledges in
enamel are visible and can be felt with a probe. A thin band of enamel at the gingival margin
may be observed on the labial and palatal aspect of maxillary incisors. Teeth may appear
darker as the enamel thins and the yellow dentine increasingly shines through/is exposed.

On both occlusal and smooth surfaces, the enamel acquires a rounded and glossy, shiny
characteristic.

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Clinical guidelines for dental erosion

A diagnosis of dental erosion is made more difficult because of the triad of toothwear
mechanisms and their complex interplay. While it is accepted that more than one type of
toothwear mechanism is often in existence, identifying the principal aetiology will favour
successful management. Occlusal erosive toothwear can be distinguished from attritive
lesions, which are typically sharp and flat with matching facets. Smooth surface erosive
toothwear can be distinguished from abrasive lesions, which are often wedge shaped, located
at the cervical margin with sharp edges at right angles to the enamel surface. An accurate
history will also help to elucidate the principal aetiology of toothwear defects.

Radiographically, occlusal surfaces may appear eroded with loss of enamel and dentine
thickness.

Patients complain of poor aesthetics once a significant volume of enamel and dentine becomes
lost, resulting in shortened anterior teeth and/or dentinal exposure. This is the common
complaint on presentation rather than sensitivity or any functional difficulty.

Useful means of estimating the current activity of erosive wear include reports of dentine
hypersensitivity and the absence of staining. These indicators suggest progression of erosive
toothwear.

Management: preventative treatment

As dental erosion is progressive, preventative measures delivered when there are only
early signs of erosive toothwear can be particularly effective in reducing the morbidity and
dental intervention experienced by patients. The main objectives of prevention are to reduce
modifiable factors (extrinsic acids), to appropriately manage non-modifiable factors (intrinsic
acids), and to record and monitor the erosion.

An ‘active monitoring’ philosophy is recommended, especially if there are no patient reported

concerns regarding pain/sensitivity, function or aesthetics. Clinically, if this approach is to be
adopted, it must also be ensured that the remaining tooth structure will remain favourable to
maintaining a comfortable, functional and aesthetic dentition in the long term, and that further
loss of structure would not preclude or complicate restoration if this becomes necessary.

Patient information leaflets

These are very useful and allow patients to consider risk factors, behaviours etc in their own
time. Patient information leaflets are produced by some companies or they can be made ‘in
house’.

Recording and monitoring erosion

Regular monitoring of dental erosion should be established on an individual basis and will help
to ascertain whether there is arrest or progression of the pathology. Records can also provide
information on the efficacy of the preventative measures implemented.

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 Clinical guidelines for dental erosion

In children and adults, good quality study casts and photographs aid the monitoring of
dental erosion. While photographs can be stored digitally, safe storage of study casts can
be problematic unless scanning and digital models are available. In adults, a silicone putty
impression of the worst affected area is more readily stored with the patient notes and may
be a helpful tool to assess progression. At a subsequent recall appointment, the putty index is
sectioned labiopalatally and placed over the teeth. Any gap between the putty index and the
tooth surface indicates progress of the erosion/wear and possible poor compliance with lifestyle
changes. In children, growth and dentoalveolar development will preclude accurate seating of a
putty index at review.

Many different clinical indices have been proposed and experts in the field have recommended
the use of the Basic Erosive Wear Examination.82 As per the Basic Periodontal Examination,
the mouth is divided into sextants and the most severely worn tooth is graded according to
a grading system (0 = no erosion; 1 = initial loss of enamel tooth surface texture; 2 = distinct
defect, hard tissue loss <50%; 3 = hard tissue loss ≥50%). The scores for each sextant are
added and the cumulative total is linked to a recommended management plan. As with any
other clinical index, it is subjective and discrimination between the various grades can be
difficult.83 It has been argued that the ability to achieve several goals effectively with one index
(monitor and clinical treatment need) is questionable.84,85 Nevertheless, it does introduce some
level of standardisation of recording erosion progression in the clinical notes.

Digital scanning may also be employed effectively to record erosive toothwear, entirely
eliminating issues with physical storage of measurement indices.86 This method of recording
erosive toothwear may become more commonplace with further adoption and development
of this technology. Novel research into optical coherence tomography may prove useful in the
measurement of erosive tooth loss in the future.87

If other oral risk factors are low, recall interval of one year for adults and six months for children
is reasonable.

Dietary analysis
Patients should be instructed to record a minimum three-day diet history (including a weekend).
All food, drink and medication consumption should be recorded with timings. Patients should
be encouraged to complete their diet history sheets as accurately and honestly as possible by
emphasising that their resulting tailored management plan will be more effective. On review of
the completed dietary history sheet, all acidic components should be highlighted and particular
note should be made of acidic components consumed between meals.

In addition to asking patients to complete a diet history sheet, the following questions will
highlight habits with an associated increase in erosive damage:47

• Do you like to ‘graze’ on acidic foods/sip acidic drinks over long periods?
• Do you swish, hold or swill acidic drinks prior to swallowing?
• Do you enjoy heated acidic beverages (eg hot cordials, fruit teas, hot water with lemons)?

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Clinical guidelines for dental erosion

Dietary counselling

While there is some evidence that one-to-one dietary interventions in the dental setting
can change a patient’s behaviour, there is no robust evidence relating to the effectiveness
of different strategies to apply when providing dietary advice for the prevention of dental
erosion.88,89 Counselling, however, must be tailored to the individual and is only possible after
the diet has been assessed thoroughly. Realistic, clear goals should be established to eliminate
or reduce erosive challenge. The benefits of a balanced healthy diet should be emphasised
and advice on limiting foods such as acidic fruits and vegetables, which have recognised
health benefits, should only be given to those individuals where excess consumption has been
identified as a risk factor.
Prior to giving specific dietary advice, a clear explanation of the difference between erosion
and caries is advisable as the public confuse these terms and believe them to be synonymous
pathologies. This is especially relevant to artificially sweetened diet drinks, which patients
may feel are a better alternative to full fat varieties owing to their low sugar, not realising that
their highly acidic component will contribute to the erosive process. Specific dietary advice to
emphasise to those susceptible to erosive toothwear includes:

• Reduce the frequency of dietary acid intake (if relevant).

• Limit acidic foods and drinks to mealtimes (if relevant) as this is the time of maximum
salivary flow and increased buffering capacity. For the same reason, acidic intake should
be avoided at bedtime and during the night.
• Avoid dietary habits that extend the length of time of contact between the dietary acid
and tooth surface (eg grazing on fruit, sipping/swishing/holding of acidic beverages). It is
therefore advisable that drinks are consumed quickly or if consumed slowly, placing a wide
bore straw towards the back of the mouth is advisable to reduce contact of acidic fluid with
the teeth.90,91
• Avoid hot acidic beverages or wait for these to cool before drinking.57
• Consumption of water, plain sparkling water or milk should be promoted as alternatives to
acidic beverages.
• Chew sugar free gum after an acid exposure. Chewing sugar free gum increases salivary
flow and encourages tooth remineralisation92 but this may not be the case for acid
containing gums.93
• Finishing a meal or following an acid exposure with cheese or milk will neutralise intraoral
acid.94
• Where possible, chewable or liquid formulations of acidic medications should be changed.
Liaison with the GP will be needed to ensure a safe switch to an alternative preparation.
• Avoid mechanical toothbrushing immediately after exposure to acid (see Oral Hygiene).

GORD, vomiting and rumination

Patients should be questioned regarding symptoms of GORD (see Gastro-oesophageal reflux
disease page 8) although it should be remembered that a proportion of patients suffer with
silent reflux. Many patients with GORD will present having self-medicated with over-the-counter
medicines. Dentists should refer (with the patient’s permission) to the patient’s GP where
GORD is suspected as an aetiological factor for presenting with erosive tooth loss.

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 Clinical guidelines for dental erosion

Referral to gastroenterology is made in the following instances:

• if symptoms interfere with daily life;

• if previous tests for GORD were either inconclusive or equivocal;
• if after elimination of dietary factors and after a period of review, erosion progresses;
• if there is no other obvious cause of erosion;
• if severe erosion is present, which may be unilateral and affecting the buccal surface.

Where GORD is suspected or has been confirmed, preventative lifestyle modification should
also be encouraged to help avoid reflux provoking foods/drinks, such as alcohol, vinegar, fatty
foods, coffee, black tea, peppermint, carbonated drinks, chocolate and meals before bedtime.
Chewing sugar free gum may also be recommended in such patients with the benefits of
increasing salivary flow and swallowing frequency.75

Patients with a medical disorder that has a sequela of repeated vomiting (see Vomiting page
9) may be under the care of a medical professional already but this needs to be confirmed and
where medical intervention has not been sought, a referral to the patient’s GP is appropriate.
Dental professionals may be the first to suspect signs of an eating disorder. Patients with an
eating disorder may benefit from psychological counselling, arranged through the patient’s GP.
This is a sensitive undertaking and care is needed regarding the maintenance of confidentiality
in teenage patients. Those who suffer from frequent vomiting should be advised to rinse
afterwards with a fluoride containing mouthrinse, or milk or water when this is unavailable.

Rumination syndrome is considered a learnt behaviour and management may involve elements
of behavioural psychology. Referral to the patient’s GP is advised in these cases.

Oral hygiene, remineralisation and desensitisation

Oral hygiene
An appropriate non-traumatic toothbrushing technique designed to effectively remove plaque
in combination with a low abrasive toothpaste should be recommended for patients with
dental erosion.95 Advising patients to not brush their teeth after an acidic episode to allow
remineralisation of the softened enamel and prevent further tooth loss is a matter of dispute
among researchers.26,50,75 Historically, it was advocated to not brush after an acid challenge
as the acid softened tooth surfaces would be more susceptible to abrasion.96,97 More recently,
it has been argued that saliva does not remineralise softened enamel quickly and as such,
tooth surface loss will occur regardless of whether toothbrushing is performed soon after an
acidic exposure. It is further suggested that not brushing after an acidic exposure denies the
opportunity of exposure to fluoride, which is helpful to aid remineralisation and prevent caries.26

Based on a recent observational cross-sectional study98 and case controlled study,50 it may be
appropriate to advise patients with erosive toothwear to not brush immediately (within 10 minutes)
after an acidic episode and a fluoride containing mouthwash may be used as an alternative.

Remineralisation
Fluoride agents (especially those containing stannous fluoride or stannous chloride) should
be used as part of the preventative management of erosive toothwear. These include fluoride
mouthrinses and toothpastes.26 Alternatively, conventional high fluoride toothpastes and
mouthwashes may be prescribed. High fluoride preparations need to be used in caution in
those under six years old.99

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Clinical guidelines for dental erosion

The mechanism by which conventional fluorides such as sodium fluoride and amine fluoride
prevent erosive demineralisation is through the formation of a calcium fluoride layer.100 This
acts as a physical barrier to the acids, and as a reservoir of calcium and fluoride ions that can
be released during an acid attack.⁶ Conventional fluoride products can therefore potentially
slow the progression of toothwear. It is thought, however, that under the conditions of an acidic
attack, the protection of a calcium fluoride layer is short lived. More recently, research into the
addition of polyvalent metal ions (such as stannous or titanium) to fluoride toothpastes has
yielded promising results in preventing erosive demineralisation.⁶ These metal cations have
been shown to make the tooth surface more resistant to dissolution during an acid exposure.

Toothpaste application prior to an erosive challenge seems to be favourable compared

with tooth cleaning after exposure. In practice, it may seem unlikely that patients prone to
erosive toothwear will execute a fluoride regime before an acid attack such as vomiting
although application prior to sleeping and overnight reflux may consequently be of benefit.101
Nevertheless, the effectiveness of fluoride in typical toothpaste concentrations may be
dependent on the acid attack.102

Some newer ‘enamel care’ dentifrices have been shown to provide enhanced resistance of
enamel and dentine to acid challenge, and may aid remineralisation although prospective
randomised clinical trials have not been reported to date.103–105

Fluoride varnishes in patients who have a high frequency of acid exposure are likely to offer
protection for a short duration and be cost ineffective.83 Furthermore, the ‘protective’ effect
offered by these varnishes is more likely related to a mechanical, physical effect than due to
remineralisation.6

Sugar free chewing gum increases salivary flow and will also aid remineralisation.92

Desensitisation
Patients with significant erosion and dentine exposure may complain of tooth sensitivity.
This may also be an indication that the erosion is still active. The use of fluoride mouthrinses
and varnishes is beneficial but they must be used frequently and regularly. A high fluoride
toothpaste may be helpful as long as it is not also highly abrasive. Other products such
as specially formulated toothpastes for sensitive teeth or GC Tooth Mousse® may also be
useful. Application of a resin sealant or dentine bonding agent may also reduce sensitivity
temporarily.26

Other/novel preventative strategies

Dentine bonding agents applied to areas of exposed dentine have been shown to reduce
further erosive tooth loss.106 In a small scale trial, the application of fissure sealant to the palatal
surface of worn maxillary anterior teeth reduced erosion progression by up to nine months.107

Recent in vitro studies suggest that the modification of the enamel pellicle (also referred to as
acquired pellicle engineering) may play a role in the prevention of erosion.108 In broad terms,
this process is based on the principle that the dental pellicle, rich in proteins, is known to offer
some form of protection to the tooth surface by erosive attacks. For this reason, modification of
this layer may be a useful strategy in preventing erosion.

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 Clinical guidelines for dental erosion

Management: restorative treatment

Restorative, operative intervention for erosive wear is necessary to rehabilitate function and
aesthetics as well as to eliminate painful symptoms. Additionally, interventive treatment may be
indicated to preserve the remaining structural integrity of the eroded dentition and circumvent
more complicated intervention at a later date. Importantly, restorative management of erosive
toothwear should be preceded by or used in conjunction with the aforementioned preventative
strategies.

Ideally, in both children and adults, aetiological factors should be identified first and brought
under control. This may involve a period of monitoring as outlined previously before definitive
restorative treatment is commenced. Clearly, the patient’s desire to improve appearance and/or
reduce sensitivity may hasten the start of interventional treatment.

Primary dentition
In the primary dentition, if the child is not experiencing any symptoms, restorative treatment
is not indicated. If teeth are sensitive, small areas of erosion may be covered with composite
resin. Larger areas may require placement of composite crowns on anterior teeth and stainless
steel crowns on posterior teeth. For severe symptoms, extraction of the offending teeth may be
necessary.

Mixed dentition
In the mixed dentition stage, the permanent dentition should be treated conservatively by either
long-term monitoring or the addition of dental composite resin to eroded surfaces. Dentine
bonding agents (without dental composite addition) can offer short-lived dentine protection
(up to 3 months) while unfilled fissure sealant in combination with a compatible, self-etching,
single stage adhesive has been shown to confer protection to the palatal surface of maxillary
anterior teeth from toothwear for periods of up to nine months.109,110 The adaptive capacity of
the stomatognathic system during growth may be greater than in adulthood and so restoration
of the eroded occlusion including guiding surfaces has not resulted in reports of postoperative
problems.

Minimal space is required to bond composite resin without increasing the occlusal vertical
dimension (OVD). Cupped and grooved surfaces can be restored to the enamel rim, which
does not usually involve an increase in the OVD. Dentine surfaces should be cleaned
with pumice/water or slow speed rose head burs prior to etching in order to remove the
salivary pellicle and enhance bonding resin infiltration/penetration of sclerotic dentine. The
polyalkenoates or glass ionomers are themselves susceptible to acid erosion/dissolution and
have no application in the eroding dentition.111 There is also weak evidence that the surface
hardness of microfilled composite and resin modified glass ionomer is significantly reduced
following short immersion in acidic beverages although this has not been examined in vivo.112

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Clinical guidelines for dental erosion

Permanent dentition
The management of erosion in the permanent dentition follows the guidance in the previous
section.

The treatment of erosive wear in the permanent dentition can range from relatively simple and
localised interventions to more complex treatment planning including full mouth rehabilitation.
Previous restorative approaches used for rehabilitation of the eroded permanent dentition
commonly involved extensive conventional crown and bridgework or removable overdentures.
While these treatment modalities may still have a place in the management of erosion, the
advancement of adhesive technology has meant that less destructive options for restoration
are now available and used widely in general dental practice. These more conservative
approaches can be applied successfully and predictably, and should be considered in the first
instance.

Regardless of the level of restorative intervention, the patient naturally needs to be made
aware of the cost and time implications, in addition to the potential future maintenance burden.
It is also clearly necessary that definitive restoration of the eroded permanent dentition requires
prior elimination of all primary disease as well as the preventative measures outlined above.

Decision making and treatment strategies in erosive toothwear

Assessment of the space in the intercuspal position (ICP) is the first step in decision making.
As the erosive wear process often happens gradually, dentoalveolar compensation occurs to
re-establish ICP contacts and maintain masticatory function, resulting in maintenance of the
OVD and facial proportions. This leads to a lack of interocclusal space for restoration.

If the toothwear process has been rapid and has exceeded the physiological mechanisms
of tooth eruption, then interocclusal space may be present in the ICP as dentoalveolar
compensation has not had time to occur. Where space is present for restoration, restorations
may be placed comparatively easily by conforming to the patient’s existing ICP. This scenario is
relatively uncommon and often there will be no space for restoration.

Localised toothwear presents frequently with an OVD within normal limits and a lack of
interocclusal space for restoration. In generalised toothwear, two situations can occur:
dentoalveolar compensation has occurred, and there is maintenance of the OVD and facial
proportions; or there is no compensation with an increase in freeway space, loss of OVD and
mandibular overclosure.113 This latter situation is seen more often in partially dentate patients
presenting with loss of the posterior dentition.114

Localised erosion
Labial/buccal wear and small occlusal cupped lesions
Where wear is localised to the labial or buccal surfaces only, restoration can be achieved
with direct or indirect composite restorations or veneers. Where the labial wear has been
more significant (and ideally, where a ring of enamel remains), ‘no prep’ adhesively bonded
feldspathic or reinforced glass-based ceramics can be considered.

Localised cupped occlusal sites may be restored with occlusal composite. These sites are
prone to further erosive attacks owing to potential pooling of acids, and must therefore be
monitored along with ongoing preventative measures and advice.

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 Clinical guidelines for dental erosion

Palatal wear of maxillary incisors

The well established management of palatal wear of the maxillary incisors has been to utilise
a ‘Dahl appliance’.115 This is, in effect, an anterior bite platform that takes the posterior teeth
out of occlusion. It promotes relative axial movement of anterior and posterior teeth resulting in
creation of space for the restoration of eroded anterior teeth. The interocclusal space created
occurs through a process of combined intrusion (40%) and extrusion (or ‘compensatory
eruption’) (60%). There is also some suggestion of mandibular repositioning occurring
concomitantly.111 It is thought that re-establishment of the separated occlusal contacts occurs
in most cases within 4–6 months but in some cases, this may take up to a period of 18–24
months.116 Localised increases in the OVD are extremely well tolerated and have become
entirely predictable as a treatment modality. Good patient understanding of the treatment,
however, is a prerequisite for success of this technique.

The first iteration of the Dahl appliance was a removable cobalt-chrome anterior bite
platform.115 Subsequently, a fixed anterior bite plane has been utilised,117 in place of a
removable appliance as described originally, which reduced the need for patient compliance
with respect to the time the appliance was in place; as such, it produced more predictable
results in a shorter period. Clinical studies now support the concept of restoring the worn upper
anterior teeth at an increased OVD without the interim stage of a removable, or fixed, Dahl
appliance as the restorations themselves have a ‘Dahl effect’.118 Once space has been gained,
then restoration of the anterior teeth may be carried out by a variety of means.

In this clinical scenario, palatal veneers in metal, or direct or indirect composite resin
restorations can provide an acceptable functional and aesthetic outcome while being cost
effective, minimally abrasive to antagonists, minimally invasive and repairable.109 Direct
composite application can be freehand or with the use of customised matrices. Various
techniques have been described that are largely dependent on operator preference and
the degree of laboratory support available. Contemporaneous summaries describing these
methods are referenced for further support.109,110

There is good evidence that both direct and indirect palatal composite restorations placed
according to manufacturers’ instructions at an increased OVD perform favourably in
combination with dentine bonding although opinion suggests that these should be placed
in relatively thick sections to maximise their longevity and where there is sufficient posterior
support.111,119–121 In general, major failure is uncommon in the first five years after placement
although minor wear, marginal discolouration and marginal fracture are likely. A careful
explanation is therefore necessary of the trade-off between the significant biological benefit
with regard to the far less destructive nature of these adhesive restorations and their
maintenance compared with traditional restorative methods.111,118,122,123

Where palatal erosive wear is severe or occurring in combination with attrition, a more durable
material may be indicated. Palatal gold and non-precious metal veneers have been described
as favourable materials in this clinical scenario.109,124–126 In these cases, the palatal metal
veneer is bonded and used as a matrix to guide build-up of the labial and incisal aspects to
the desired form if an increase in incisal length is also desired.126 No preparation of the palatal
surface is required other than smoothing any sharp enamel margins. Bonding should be
completed with an opaque adhesive resin cement.

Regardless of the material used for restoration of maxillary palatal erosive defects, even
contacts with restorations should typically be obtained on the six anterior teeth, with smooth,
evenly distributed anterior guidance in protrusion lateral excursions where possible.

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Clinical guidelines for dental erosion

Incisal/labial wear of mandibular incisors

Incisal wear of mandibular incisors can be challenging to manage as their diminutive nature
presents a reduced surface area for bonding. Indirect full coverage restorations also present
increased risk of loss of pulpal vitality in these teeth due to the amount of tissue removal
required relative to the volume of the unprepared tooth. For this reason, it is generally accepted
that minor incisal wear should be monitored and preventative measures employed.

In more advanced mandibular incisal wear, where there is inadequate space in the ICP, direct
composite restorations at an increased OVD as part of the Dahl approach have been shown
to have good survival rates.119,127 Dentine bonded crowns involving minimal cervical and incisal
preparation may also be considered in more severe cases or in cases where composite resin
has failed repeatedly. Caution should be exercised over their use in patients with parafunction
and it is reported that their success is predicated on an ‘enamel ring’ being present.119

Posterior occlusal wear

Posterior occlusal wear may be addressed in a similar fashion to anterior palatal wear by
placing restorations in a supraocclusion and employing the Dahl concept.113,128 Should anterior
contacts not re-establish, consideration may need to be given to providing further restorations
on the remaining anterior teeth to re-establish even and balanced contacts throughout the
arch. This would also apply to anterior restorations placed at an increased OVD, as described
previously (see Palatal wear of maxillary incisors).

Indirect restorations including partial coverage restorations and onlays may be indicated in
the clinical scenario of posterior occlusal wear. Few studies to date have examined the use
of composite restorations for the restorative management of worn posterior teeth. While an
early study reported a high failure rate (fracture or complete loss of restoration), a microfilled
composite material was used and a hard acrylic stabilisation splint was not provided.129 Later
case reports using a hybrid composite resin and full coverage, heat cured acrylic resin splints
for ongoing supportive care may explain a far greater level of success, albeit on limited
numbers of patients.130

It has also been argued that application of a composite resin provides the clinical advantage
of allowing the patient to accommodate to the occlusal changes and enabling the clinician to
make any adjustments. The composite resin may then be readily replaced with a restorative
material with increased durability if needed.128

Where signs of early posterior tooth surface loss are observed and there is an absence of
disclusion in lateral excursions, metal palatal veneers on the canines acting as ‘canine risers’
can be used to re-establish a mutually protective occlusion and protect the posterior teeth from
further wear.

Other approaches to localised toothwear

Adhesive, additive measures employed as part of the Dahl approach, as outlined above, are
the restorative strategies of choice in localised toothwear, their distinct advantage being that
they are biologically conservative of tooth structure, which is especially desirable in a scenario
where existing tooth tissue has already been lost. The conventional approach employs
occlusal/incisal reduction to make space for a full or partial coverage indirect restoration. This
increases the risk of pulpal necrosis131 and reduces the structural integrity of the already worn
tooth.

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 Clinical guidelines for dental erosion

Generalised erosion
The treatment strategies for restorative management in cases of generalised erosion
principally include planning for an increase in the OVD and reorganising the occlusal
scheme in the retruded axis position or for space creation through occlusal equilibration (if a
discrepancy exists between the retruded contact position and ICP). The latter approach rarely
provides sufficient space alone and involves preparation of already compromised teeth. Its
use as a restorative approach is consequently limited.

Traditional conventional strategies for generalised toothwear include tooth reduction to

achieve appropriate space for restoration with full or partial coverage indirect restorations,
as described previously for localised wear. The advent of reliable adhesive materials means
more destructive and invasive options are indicated less often, and more conservative
designs (such as indirect onlays) can be provided utilising adhesive luting cements.

Increases in the OVD are well tolerated by dentate patients owing to the proprioception
through the periodontal ligament and associated neuromusculature.113 Clinical studies in
adults have also not reported any long-term increase in temporomandibular joint dysfunction
or dental problems.102,103,132,133 Occlusal splints are therefore not necessary to simply test an
increase in the OVD. However, they may still be indicated in this cohort for other reasons,
such as pre-restorative stabilisation to ensure a reproducible jaw relationship, to protect
worn teeth/new restorations if there is an attritive co-factor and in the management of
temporomandibular joint dysfunction.113 Prescribing increases in the OVD requires careful
planning and is supported by the use of appropriately mounted study casts, diagnostic wax-
ups at the intended vertical relation and diagnostic previews with clinical ‘mock try-ins’.

There are limited data to support the use of specific materials or techniques in generalised
toothwear.113 Of the few studies available, one has compared the use of indirect materials
with resin composites in cases of severe generalised toothwear, reporting ten-year survival
rates of 74.5% and 62.0% respectively.134 This difference was not statistically significant.
Furthermore, biological failures were more highly associated with indirect restorations and
mechanical failures with composite resin. These latter failures were recognised as being more
straightforward to manage and amenable to repair. Gold restorations were associated with
the fewest failures overall. In a more recent study, low failure rates have also been reported in
the use of direct hybrid composites for cases of generalised toothwear.135

In selecting appropriate restorations, a prudent approach is to conduct a tooth-by-tooth

assessment and prescribe appropriate restorations based on the structural integrity with any
restoration or core removed. Parafunctional habits may also influence selection of materials.
A combination of indirect or direct composite restorations anteriorly with the use of partial
coverage adhesive gold, metal or reinforced glass ceramics posteriorly could be considered
a conservative approach in such cases. As further studies are conducted, posterior direct or
indirect composite restorations may also become an evidence-based treatment strategy for
full mouth reconstructions in generalised wear.

When the generalised toothwear is deemed very advanced, it can be more appropriate to
reduce the teeth further and provide overdentures.114 By maintaining overdenture abutments
(versus extraction), the advantages include continued proprioceptive feedback, a reduction in
ridge resorption with a resulting increase in denture stability and support, and the potential to
use precision attachments such as magnets or studs to increase retention. Conversely, caries
and periodontal disease associated with abutment teeth is increased.136 Onlay or overlay

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Clinical guidelines for dental erosion

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