Erosion by soft drinks of rat molar teeth assessed by digital image analysis

Susceptibility of partially desalivated rats to erosive tooth wear by calcium-supplemented beverages

OBJECTIVES

To investigate the susceptibility of partially desalivated rats to erosive tooth wear (ETW); the anti-erosive effect of a calcium-supplemented beverage; and the quantification of ETW by microcomputed tomography (micro-CT).

METHODS

The study population consisted of thirty-eight rats, divided into partially desalivated (n = 19) and normal salivary flow (n = 19). They were randomly allocated into three subgroups (n = 6-7): A-diet soda, B-diet soda + calcium, C-water (control). Solutions were provided ad libitum for 28 days, and the rats were euthanized afterwards. Each left hemi-mandible was scanned using micro-CT for enamel volume (three molars) calculation. Visual analysis of photographs of the lingual surface of first molars was performed independently by three blinded examiners. Data were statistically analysed (α = .05).

RESULTS

Micro-CT revealed no significant differences between partially desalivated or normal groups. Rats consuming A had more enamel loss than those consuming B or C, which did not differ from each other. For visual analysis, desalivation did not affect ETW. Rats consuming C showed the lowest ETW, followed by B and then A, for both partially desalivated and normal rats. Spearman correlation between the two ETW quantification methods was -.65.

CONCLUSIONS

Partial desalivation did not increase ETW. Ca-containing beverage prevented ETW. Micro-CT quantified ETW, although it was not as sensitive as visual analysis.

Analysis of the erosive effect of different dietary substances and medications

Excessive consumption of acidic drinks and foods contributes to tooth erosion. The aims of the present in vitro study were twofold: (1) to assess the erosive potential of different dietary substances and medications; (2) to determine the chemical properties with an impact on the erosive potential. We selected sixty agents: soft drinks, an energy drink, sports drinks, alcoholic drinks, juice, fruit, mineral water, yogurt, tea, coffee, salad dressing and medications. The erosive potential of the tested agents was quantified as the changes in surface hardness (ΔSH) of enamel specimens within the first 2 min (ΔSH2-0 = SH2 min - SHbaseline) and the second 2 min exposure (ΔSH4-2 = SH4 min - SH2 min). To characterise these agents, various chemical properties, e.g. pH, concentrations of Ca, Pi and F, titratable acidity to pH 7·0 and buffering capacity at the original pH value (β), as well as degree of saturation (pK - pI) with respect to hydroxyapatite (HAP) and fluorapatite (FAP), were determined. Erosive challenge caused a statistically significant reduction in SH for all agents except for coffee, some medications and alcoholic drinks, and non-flavoured mineral waters, teas and yogurts (P < 0·01). By multiple linear regression analysis, 52 % of the variation in ΔSH after 2 min and 61 % after 4 min immersion were explained by pH, β and concentrations of F and Ca (P < 0·05). pH was the variable with the highest impact in multiple regression and bivariate correlation analyses. Furthermore, a high bivariate correlation was also obtained between (pK - pI)HAP, (pK - pI)FAP and ΔSH.

Erosion--diagnosis and risk factors

Dental erosion is a multifactorial condition: The interplay of chemical, biological and behavioural factors is crucial and helps explain why some individuals exhibit more erosion than others. The erosive potential of erosive agents like acidic drinks or foodstuffs depends on chemical factors, e.g. pH, titratable acidity, mineral content, clearance on tooth surface and on its calcium-chelation properties. Biological factors such as saliva, acquired pellicle, tooth structure and positioning in relation to soft tissues and tongue are related to the pathogenesis of dental erosion. Furthermore, behavioural factors like eating and drinking habits, regular exercise with dehydration and decrease of salivary flow, excessive oral hygiene and, on the other side, an unhealthy lifestyle, e.g. chronic alcoholism, are predisposing factors for dental erosion. There is some evidence that dental erosion is growing steadily. To prevent further progression, it is important to detect this condition as early as possible. Dentists have to know the clinical appearance and possible signs of progression of erosive lesions and their causes such that adequate preventive and, if necessary, therapeutic measures can be initiated. The clinical examination has to be done systematically, and a comprehensive case history should be undertaken such that all risk factors will be revealed.

Evaluation of a profilometrical method for monitoring erosive tooth wear

The in vivo monitoring of erosive wear is difficult because lesions mostly progress relatively slowly and reliable reference points are difficult to obtain. To date, only a few methods for clinical monitoring of erosive loss have been described, which either require extensive equipment or do not provide sufficient sensitivity. The aim of the present study was to evaluate, using study models (epoxy resin material), a procedure that permits the reliable and accurate monitoring of erosive substance loss within acceptable observation periods. The method is the profilometric measurement of erosive tissue loss using acid-resistant markers, which represent both a reference area and a structure for the defined retracing of a given erosive lesion surface. The study model magnified values slightly (2.8%; not significant), the precision was < 4 microm, and the repeatability was good (95% limits of repeatability ranging from -4.7 to 5.2 microm). The estimated detection threshold for erosive loss is 15 microm, which appears to be adequate for monitoring. The method is indicated for special dental care in cases of severe dental erosion (e.g. eating disorders) and for clinical studies.

In vitro quantification of changes in human dentine tubule parameters using SEM and digital analysis

Dentine hypersensitivity is recognized as a pain arising from fluid movement within dentine tubules that are open to the oral environment. Blocking the tubules is considered to be the principal aim of treatment, and the accurate assessment of tubule occlusion is the primary goal of many in vitro studies. This assessment usually comprises either measuring tubule permeability or scanning electron microscope examination of the dentine surface. Several scanning microscopy studies have claimed to quantify tubule occlusion, but are descriptive, qualitative or semi-quantitative evaluations. The present study was undertaken to assess the use of digital image analysis in quantifying the effectiveness of a selected desensitizing agent from micrographs of control and treated dentine surfaces. Using a dentine disc model, an accurate methodology was sought to investigate the occluding potential of Butler Protect (J.O. Butler, Chicago, IL, USA). Subjective examination of the images indicated there was little difference after a single application, but considerable effect after 20 applications. Quantitative digital analysis of a test image, demonstrated reproducibility between two examiners when used in fully- and semi-automated mode. After a single application of Butler Protect, multilevel statistical modelling demonstrated decreases in tubule area and maximum, minimum and mean diameter measurements (P < 0.001), whereas single level analysis showed increases in area and maximum and mean diameters. Multiple application of Butler Protect demonstrated even greater decreases in all parameters (P < 0.001). This quantitative methodology was reproducible between examiners and, when combined with good controls and multilevel statistical modelling, was able to discriminate a single application of desensitizing agent.

Diagnosis and management of maxillary incisors affected by incisal wear: an interdisciplinary case report

In the attempt to restore anterior teeth affected by erosion and bruxism, many clinicians have been frustrated with the constant restorative failures. Frequently, these failures are attributed to the restorative materials employed, especially in cases in which composite resins are used. However, some flaws of the restorations are related to the oversight of occlusal principles. The purpose of this article is to discuss the etiology, signs, and symptoms of incisal wear, with special attention to that caused by bruxism and chemical erosion. Relatively simple management techniques (e.g., occlusal adjustment, adhesive restorations) are proposed, and the diagnosis and management of a representative clinical case is presented.

CLINICAL SIGNIFICANCE

In some cases of bruxism and/or dental erosion, it is possible to acquire space to recuperate the esthetics and function of maxillary incisors affected by incisal wear through a conservative treatment associated with the control of the etiologic factors.

Scanning electron microscope study of the effects of soft drinks on etched and sealed enamel

The purpose of this study was to determine the effects of cola and other acidic drinks on etched tooth enamel in a simulated oral environment. The test beverages were cola, orange soda, lemon soda, and sparkling mineral water. Sixty extracted premolars were divided into an experimental group (n = 40) and a control group (n = 20). Half of the buccal surface of each tooth in the experimental group was coated with wax. The teeth were etched for 60 seconds with 37% phosphoric acid, and half of the teeth were also bonded. The experimental group was further divided into 4 subgroups of 5 teeth each, and each subgroup was exposed to 1 of the test beverages in a thermocycling apparatus. The apparatus was designed to keep the teeth in artificial saliva for 2 hours and in the soft drink at room temperature for 15 minutes. This procedure was performed 3 times a day for 5 days. The control group was also divided into 4 subgroups of 5 teeth each. Half of the buccal surface of each tooth in 2 subgroups was coated with wax, and the teeth in the other 2 were left uncoated. One waxed and 1 unwaxed subgroup were then etched, and the other waxed and unwaxed subgroups were etched and bonded. The waxed subgroups were stored in artificial saliva for 5 days, and the unwaxed subgroups were examined without further exposure to liquids. Surfaces exposed to acidic soft drinks were compared with control surfaces under a scanning electron microscope. Defect zone borders were observed between the exposed areas and the wax-coated areas of teeth in the experimental groups, especially the subgroups exposed to cola, orange soda, and lime soda. Fewer defect zones were observed on teeth exposed to sparkling mineral water. The results indicate that acidic soft drinks cause enamel demineralization on etched tooth surfaces.

Modern methods for assessing the cariogenic and erosive potential of foods

Assessment of the acidogenic and cariogenic erosive potential of foods requires the use of reproducible and standardised methods. The methodology laid down at the San Antonio conference in 1985 remain today the basis for research on and the testing of foods. The 1999 workshop has updated the appropriate methodology and introduced guidelines on the testing of erosive potential of foods. It is to be hoped that researchers wishing to evaluate foods and their effect on the teeth will continue to use these methods.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Dentine hypersensitivity: the effects of brushing desensitizing toothpastes, their solid and liquid phases, and detergents on dentine and acrylic: studies in vitro

Dentine exhibiting symptoms of dentine hypersensitivity has tubules open at the dentine surface and patent to the pulp. The mechanisms whereby dentinal tubules are exposed is ill understood but probably involves a variety of abrasive and/or erosive agents. This study in vitro examined the quantitative and qualitative effects of toothpastes, their solid and liquid phases and detergents on dentine and acrylic. Abrasion of dentine and acrylic were measured by surfometry. Morphological changes to dentine were assessed by scanning electron microscopy. Abrasion of dentine and acrylic by toothpastes increased with increasing brushstrokes with marked differences in the extent of abrasion between different pastes. Brushing dentine with water or detergents produced progressive abrasion but which appeared to plateau around 2 microm loss. Water and detergents produced minimal effects on acrylic. At 5000 strokes dentine abrasion by solid phases was less than the parent toothpastes but the ranking order of abrasivity was the same as the parent toothpastes. Loss of dentine produced by liquid phases was minimal and in the order of 1-2 microm. Observationally, all toothpastes removed at least the dentine smear layer to expose many tubules; with one desensitizing product leaving a particulate deposit occluding most tubules. The solid phases of the toothpaste produced identical morphological changes to the parent paste. The liquid phases and detergents all exposed dentinal tubules by 5000 strokes. Water had little or no effect on the dentine smear layer. It is concluded that toothpastes, solid phase, liquid phase and detergents have the potential to abrade or erode dentine to a variable degree and result in tubule exposure. The effects of the liquid phases and detergents appear limited to the removal of the smear layer. Such detrimental effects seen in vitro could have relevance to the aetiology and management of dentine hypersensitivity. Toothpaste formulations which despite exposing tubules have ingredients capable of occluding tubules may be an area of development for such products.

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

OBJECTIVE

Acidic soft drinks are frequently implicated in dental erosion, but there are limited supporting data. Research is problematic due to the insidious nature of erosion and accuracy in assessing tissue loss. The aim of this study was to develop and validate, using a negative control, a model to accurately measure erosion in situ due to a single aetiological agent over a relatively short time period.

METHODS

An intra-oral appliance capable of retaining an enamel sample was designed in order to assess the effect of orange juice consumption on enamel. The study was a single centre, randomized, placebo controlled, blind, crossover design.

RESULTS

Ten subjects, each consuming 11 of orange juice per day for 15 days, showed significantly more erosion on the enamel specimens than the same subjects consuming 11 of water per day over the same time period, measurements undertaken with surfometry. The same investigation was performed in vitro. Again, orange juice was significantly more erosive; indeed, it was in the order of 10 times that produced in situ. Surface microhardness testing in situ and in vitro demonstrated statistically significant differences between exposed and unexposed areas after orange juice treatment.

CONCLUSIONS

Changes produced by water either in situ or in vitro were always well within the baseline measurement parameters (+/- 0.3 micron) set down for the method and hence validated the clinical model in terms of reproducibility and accuracy in measurement. It is concluded that this method has confirmed the erosive potential of orange juice in situ. The method could have many applications to study dental erosion under highly controlled conditions and over realistic time periods.

Correlation of microhardness and wear in differently eroded bovine dental enamel

The purpose of the study was to compare the microhardness data of differently eroded enamel surfaces with the wear caused by toothbrushing. Sixty bovine enamel specimens were polished and prepared for microhardness determination. The polished surfaces were covered with tape except for a 1.3 x 10.0 mm window. Fifteen specimens each were stored in an erosive beverage (Sprite Light) for either 1, 5 or 15 min. Each specimen was immersed in 10 ml of the beverage. The remaining 15 specimens were not eroded. Interferometrical analysis revealed that substance loss after 15 min of erosion was negligibly low (about 75 mm). In all specimens Vickers microhardness determinations were conducted on eroded (= final hardness) and non-eroded (= initial hardness) enamel surfaces. The specimens were subsequently submitted to toothbrushing abrasion using a slurry consisting of 1 g non-fluoridated dentifrice in 5 ml artificial saliva. The total amount of tooth wear due to erosion and subsequent abrasion was profilometrically evaluated. Statistical analysis revealed a significant decrease in hardness and a significant increase in wear with increasing time of storage in the erosive beverage. Overall regression analysis yielded a statistically significant correlation between both initial and final hardness and the amount of tooth wear. The correlation of abrasion and final hardness could be described by a quadratic mathematical function. It is concluded that the susceptibility of eroded enamel to toothbrushing abrasion can be correlated with Vickers microhardness values, thereby suggesting an overproportionate increase of abrasion with decreasing hardness values.

Methods of assessing erosion and erosive potential

Methods for use in vitro are reviewed first, classified under the examination of extracted teeth, chemical and physical methods, digital image analysis, scanning electron microscopy and other potentially useful techniques. Methods for recording erosion in laboratory animals are dealt with next, including techniques that can also be used in vitro, Restarski's system and various modifications of it, and digital image analysis. Thirdly the main systems and indices that have been designed for clinical use are arranged under case histories and clinical examination, scales of severity and indices of diagnosis of varying complexity. Finally, some of the main advantages and limitations of the techniques are summarized.

Lessening dental erosive potential by product modification

Current interest in dental erosion has led to increasing attention to ways in which potentially erosive products might be modified. Information on how this could be achieved has been hard to gather, and has focused chiefly on possibilities in reformulating soft drinks. The bulk of the work published on this relates to calcium and phosphate supplementation, ranging from early experimentation on saturation of a demineralising medium with tricalcium phosphate, through tests of more soluble phosphates and other calcium salts providing various levels of Ca2+ and PO4(3-), to a calcium citrate malate additive specially formulated to curb erosion by soft drinks. Opinions on the effectiveness of citrate, the practicability of reducing the acidity levels of soft drinks, and the possible applications of fluoride, bicarbonates and certain constituents of milk products are also included. Finally, an attempt has been made to summarize some of the advantages and shortcomings of the different methods, but it is clear that much further work will be needed before firm guidelines on the best routes to product improvement can be laid down.

Pathogenesis and modifying factors of dental erosion

Dental erosion is caused by acidic solutions which come into contact with the teeth. Because the critical pH of dental enamel is approximately 5.5, any solution with a lower pH value may cause erosion, particularly if the attack is of long duration, and repeated over time. Saliva and salivary pellicle counteract the acid attacks but if the challenge is severe, a total destruction of tooth tissue follows. Ultrastructural studies have shown that erosive lesions are seen in prismatic enamel as characteristic demineralization patterns where either the prism cores or interprismatic areas dissolve, leading to a honeycomb structure. In aprismatic enamel the pattern of dissolution is more irregular and areas with various degrees of mineral loss are seen side by side. In dentin the first area to be affected is the peritubular dentin. With progressing lesions, the dentinal tubules become enlarged but finally disruption is seen also in the intertubular areas. If the erosion process is rapid, increased sensitivity of the teeth is the presenting symptom. However, in cases with slower progression, the patient may remain without symptoms even though the whole dentition may become severely damaged. Regarding the role of causative agents, present data does not allow the ranking of different acids with regard to their potential of causing erosion. Neither is there consensus as to how effective fluorides are in preventing the progression of erosive lesions, or how the chemical and structural factors of tooth tissue in general might modify this pathological process.

Etiology of dental erosion--extrinsic factors

The extrinsic causes of dental erosion can be grouped under the headings of environmental, diet, medications and lifestyle. Environmental factors mainly involve exposure to acid fumes by workers in factories without proper safeguards. Swimming pools with low pH due to inadequate maintenance have also been implicated. Dietary factors have received the most attention and are likely to affect the broadest segment of the population. Most acidic foods and drinks have the potential to cause dental erosion in the human mouth. The total acid level (titratable acid) of dietary substances is considered more important than their pH, because it will determine the actual H+ available to interact with the tooth surface. Other constituents of foods and beverages will also have a modifying effect, including the calcium, phosphate and fluoride concentration, the acid type, and physical and chemical properties that influence the clearance rate from the mouth. It is not appropriate to assign relative degrees of risk to the different dietary substances except in general categories, because of the many human biological and behavioral factors that influence the clinical expression of dental erosion. The types of foods and beverages consumed, and the frequency and time of consumption are lifestyle factors that are considered most important regarding the clinical development of dental erosion. Low pH medications and oral hygiene products have also been suggested as potential causes of erosion. The combination of frequent consumption of acidic substances and overzealous oral hygiene practices may be another high risk lifestyle factor.

The use of high-phosphorus supplements to inhibit dental enamel demineralisation by ice lollies

Five new formulations of water ice lollies with a high-phosphorus (low Ca) supplementation ratio were tested for their erosiveness of dental enamel or hydroxylapatite in vitro. Compared with the basic unsupplemented lolly, all five formulations that had been prepared with additional calcium and phosphorus, but in a low Ca/P ratio, as potential inhibitors of demineralisation, were associated with significantly less attack on dental mineral, as measured by the dissolution of calcium and phosphorus.