Dental Erosion: Diagnostic-Based Noninvasive Treatment
Antonio Carlos Cardoso, MSD, PhD
While dental erosion has been the subject of discussions throughout history, it continues to receive emphasis in contemporary literature.1-4 The diagnosis of worn dentition and the establishment of restorative treatment can often be difficult, particularly when abrasion and attrition are evident. While it is beyond the scope of this article to define the terminology associated with tooth wear, it is important to note that dental erosion
is a gradual, nonbacterial process of demineralization that occurs in the hard tissues of the dentition. Erosion can be attributed to numerous factors that include the ingestion of acidic (organic and inorganic) substances,2,4-7 frequent episodes of vomiting and regurgitation, and external environmental agents.3,8,9 Although the clinical characteristics of the lesions of dental erosion are clearly discernible (Table 1), diagnosis can be complicated by the presence of abrasion and attrition.
Mechanical factors (ie, occlusal wear, mechanical toothbrushing, abrasive tongue action) often potentiate the destructive nature of acidic substances.6 The lingual surfaces of the maxillary incisors are particularly prone to hard tissue destruction due to acid insult and mechanical action from occlusion and increased tongue contacts.2 When erosion and mechanical wear occur on the lingual surfaces of the teeth, the slightly roughened surface may be perceived by the innervated tongue of the patient. This occasionally results in the development of a parafunctional habit whereby the tongue is repeatedly moved across the surface, which can cause the additional removal of enamel and/or dentin. The loss of hard tissue can also occur when the teeth are aggressively brushed following the consumption of food or beverages. Rather than risk acceleration of the demineralization process, patients would benefit from the use of a fluoride mouthrinse.
While dental erosion continues to be explored in the literature, little discussion exists with regard to its conservative treatment. This article demonstrates the use of occlusal adjustment and composite resin to reestablish proper spacing, and the restoration of teeth affected by erosion in combination with abrasion and/or attrition.
A 26-year-old male patient presented with excessive posterior and anterior tooth wear. While hard tissue damage was not observed on the facial aspect (Figure 1), clinical examination confirmed the presence of severe hard tissue damage on the lingual surfaces of the maxillary central incisors. Two red spots that represented the close proximity of the pulp were observed on these teeth (Figure 2). No obvious pulp exposures were detected, however, and the patient was asymptomatic. A deep bite was present, and the mandibular teeth contacted maxillary eroded areas. The patient exhibited indications of parafunctional habits (ie, bruxism) and denied the consumption of acidic foods and beverages — except for wine. Based on these clinical findings and the patient’s history of wine consumption, a diagnosis of dental erosion and associated dental abrasion was determined.
Due to the extent of the patient’s dental wear, preventive measures were instituted to minimize any additional hard tissue loss and to preserve the restorations that were to be placed. Once the patient was counseled on the mechanisms of dental wear (ie, erosion and abrasion), the benefits of terminating or drastically reducing the consumption of acidic substances were explained.
Once the patient was placed in centric relation (CR) (Figure 3), a difference was observed between the maximum intercuspal position and CR. The initial contact in CR existed between the medial longitudinal edge of the palatal cusp of the left maxillary first premolar and the distal longitudinal edge of the mandibular first premolar (Figure 4). The maxillary tooth was adjusted with a diamond bur in order to establish a stop on the cusp. A second contact in CR was detected on these premolar teeth and similarly reduced to create an occlusal stop. Since additional teeth were observed to be in contact throughout the arch during CR, a Lucia’s jig was fabricated in acrylic resin in order to complete the occlusal adjustment.
The fabrication of an acrylic resin jig for recording CR was initially discussed by Lucia in 1964.10 The jig was originally designed to impede the patient’s proprioceptive reflexes and thereby remove any guidance provided by the teeth and ensure perfect closure while recording CR. The jig has been further refined for several decades to aid final occlusal adjustment in CR and to retain the space required for the placement of restorations.11
Occlusal Adjustment Using Lucia’s Jig
Following the successful fabrication of the jig, it was positioned and the mandible was manipulated into CR (Figures 5 through 7). When the jig contacted the opposing mandibular tooth, the point was indicated with marking paper (Figure 8), and the jig was gradually reduced until the dental contacts were detected in the posterior teeth. The posterior occlusion was subsequently adjusted with the jig in place. This procedure was repeated until simultaneous bilateral contacts occurred on all posterior teeth and the jig.
In order to facilitate placement of composite resin, the palatal surface of the jig was cut away to expose the lingual surface of one central incisor (Figure 9). This procedure reserved the lingual surface of the adjacent central incisor for resin placement; the contralateral tooth was covered by the jig and in contact with the opposing dentition. Following the restoration of the first central incisor (Figures 10 and 11), the jig was removed and the remaining central incisor was restored. During the clinical procedure, the teeth were initially cleaned with pumice and paper strips.
Once an appropriate shade had been determined, the tooth structure was etched for 15 seconds and cleaned with water/air spray for 20 seconds. The teeth were subsequently air dried, and a dental adhesive was applied in accordance with the manufacturer’s directions. Several increments of composite resin were used to build tooth form; each increment was photopolymerized for 20 seconds. At the conclusion of these procedures, simultaneous bilateral contacts had been achieved for the posterior dentition and the palatal surface of the anterior teeth.
Once all occlusal adjustments had been completed, the teeth were reshaped and polished utilizing rotary instruments to establish the definitive topography of the restorations (Figure 12). Excess cement was removed with a #12 Bard Parker blade. An occlusal splint with 1 mm of thickness was subsequently fabricated in the vacuum-form system for use at night.
As clinicians have gained improved understanding of dental erosion and wear, reports in the literature on this subject have increased.12 Few reports exist, however, with regard to the conservative treatment — such as the reestablishment of proper spacing using occlusal adjustment and composite resin on the palatal surfaces — for these cases (Figures 13 through 17).
The two presentations in this article illustrate the clinical characteristics of dental erosion and wear. In these patients, early diagnosis and intervention were instrumental in the avoidance of extensive restorative procedures. The importance of a definitive diagnosis, preventive counseling, and conservative treatment are also highlighted. While instances of dental erosion are often difficult to treat, knowledge of the occlusal principles can simplify the procedures and enhance the result of treatment. Unfortunately, students and clinicians may find occlusal principles intimidating due to confusion that may have arisen during their university training.
Dental clinicians and students alike should be encouraged to utilize the principles of occlusion in the treatment of patients who exhibit dental erosion. The two case presentations in this article were selected to demonstrate the ease and simplicity with which these principles can be applied in clinical situations. The aforementioned restorative technique is conservative, expedient, inexpensive, and preferable to radical treatment modalities. Each restorative procedure was completed in a maximum of two appointments. It is also important to emphasize that the quantity of hard tissue removed with occlusal adjustment is minimal, particularly in comparison to the hard tissue loss of abrasion, erosion, attrition, and less conservative restorative procedures (eg, full-coverage crown restorations). Postoperative care and evaluation for these patients (as for other dental treatments) should be on a regular recall basis.
*Professor, Department of Stomatology, University of Santa Catarina, Floreanôpolis, Brazil.
†Graduate Student, Department of Operative Dentistry, University of Santa Catarina, Floreanôpolis, Brazil.
‡Assistant Professor, Division of Oral Pathology, University of Minnesota, School of Dentistry, Minneapolis, Minnesota.
- Bevenius J, L’Estrange P, Angmar-Mansson B. Erosion: Guidelines for the general practitioner. Aust Dent J 1988;33(5):407-411.
- Eccles JD. Tooth surface loss from abrasion, attrition and erosion. Dent Update 1982;9(7):373-381.
- Hazelton LR, Faine MP. Diagnosis and dental management of eating disorder patients. Int J Prosthodont 1996;9(1):65-73.
- Lussi A, Portmann P, Burhop B. Erosion on abraded dental hard tissues by acid lozenges: An in situ study. Clin Oral Invest 1997;1(4):191-194.
- Gregory HB, Curtis DA. Erosion caused by gastroesophageal reflux: Diagnostic considerations. J Prosthodont 1997;6(4):278-285.
- Hellström I. Oral complications in anorexia nervosa. Scan J Dent Res 1977;85(1):71-86.
- Levine RS. Fruit juice erosion — An increasing danger? J Dent 1973;2(2):85-88.
- Grando LJ, Tames DR, Cardoso AC, Gabilan NH. In vitro study of enamel erosion caused by soft drinks and lemon juice in deciduous teeth analyzed by stereomicroscopy and scanning electron microscopy. Caries Res 1996;30(5):373-378.
- Hastings JH. Conservative restoration of function and aesthetics in a bulimic patient: A case report. Pract Periodont Aesthet Dent 1996;8(8):729-736.
- Lucia VO. A technique for recording centric relation. J Prosthet Dent 1964;14(3):492-505.
- Lucia VO. Modern Gnathological Concepts — Updated. Carol Stream, IL: Quintessence Publishing, 1983.
- Lussi A, Schaffner M. Incidence of dental erosion over a six-year period. Caries Res 1996;30:304-305(Abstract No. 115).
Table 1: Clinical Characteristics of the Lesions of Erosion
- Diminished luster.
- Smoothing out of the developmental pits and grooves.
- Lack of macroscopic plague.
- Exposure of dentin.
- Prominent amalgam restorations elevated above surrounding tooth structure.
- Well-defined concavities of dentin on the occlusal and incisal surfaces.1