a component of many sports drinks, many of which have a pH between 3.16 and 3.70, values that can cause the dissolution of calcium ions from the enamel and can initiate the process of dental erosion (Nijakowski et al., 2022). Calcium and phosphate components of foods and beverages are important determinants of erosive potential because they influence the concentration gradient within the local environment of the tooth surface. Several calcium-enriched orange juices and sports drinks are available. The calcium enrichment makes the concentration gradient small, helping to protect against softening of the enamel surface of the teeth. Yogurt has a low pH (about 4.0) but has no major erosive effect because of its high calcium and phosphate content, as calcium may protect against dental erosion (American Dental Association, 2021). In sum, the erosive potential of food and drink is determined by various factors, including the original pH of the food or beverage, the titratable acidity after ingestion of the food or beverage (Guignon, 2020), the mineral content of Biological factors Numerous biological factors are possibly associated with the processes of erosion. These factors include functions, habits, and patterns of mandibular movement; diseases; salivary factors; tooth morphology and positioning in relation to soft tissues and the tongue; the acquired dental pellicle; oral hygiene habits; and features of the modern lifestyle (Santhiya et al., 2019; Sengupta, 2018). Saliva is the most important inherent factor for the prevention of demineralization and in the promotion of remineralization during the process of erosive tooth wear. These protective mechanisms include dilution and clearance of erosive agents from the mouth, neutralization and buffering of acids, and slowing of the rate of enamel dissolution by the presence of salivary calcium and phosphate and in the formation of the acquired pellicle on the tooth surface (Santhiya et. al., 2019; Mitrani, 2019). Conversely, erosion may be associated with low salivary flow and low buffering capacity (Johansson et al., 2017). Gastroesophageal reflux disease (GERD) has become a pervasive medical problem (Gastrointestinal Society, 2019; Mitrani, 2019). This condition represents a spectrum of disease related to injury of the esophagus and adjacent organs secondary to the reflux of highly acidic gastric contents into the esophagus, oral cavity, and/or airways. Although heartburn and regurgitation are the most common manifestations of GERD, a wide spectrum of atypical symptoms and signs ranges from noncardiac chest pain to erosion of dental enamel (Alruthea, 2020; Cesario et al., 2018). Other conditions in which recurrent vomiting forces gastric acids into the oral cavity, such as bulimia, chronic Behavioral factors Behavioral factors play a role in modifying the extent of tooth wear during and after an erosive challenge. How dietary acids are introduced into the mouth affects which teeth are contacted by the erosive challenge and possibly the clearance pattern. High erosion is associated with the habit of drinking in which the beverage is retained in the mouth for a prolonged period known as the retaining drinking technique (Hasselkvist et al., 2016; Santhiya, et al., 2019) Tooth surface loss via toothbrushing features wear on the occlusal surfaces and can be increased in the presence of an acidic diet or gastric acids in the oral cavity from conditions such as (GERD) or eating disorders (Dental Health Foundation, 2019; Delgado & Olafsson, 2019; Warreth et al., 2020;).
the food or beverage, and the ability of any of its components to complex with calcium and remove it from the tooth’s surface. Soft drink consumption has been implicated as the most significant factor in dental erosion, especially in younger individuals (American Dental Association, 2021; Noble & Faller, 2018). The frequency with which soft drinks are consumed also plays an important role, with daily consumption having a greater effect than weekly consumption (Guignon, 2020). Significant correlations with dental erosion include high levels of soft and sports drink consumption and long oral retention times before swallowing, excessive oral hygiene, mouth breathing, and the amount of palatal plaque on maxillary anterior teeth (American Dental Association, 2021; Guignon, 2020; Touyz & Nassani, 2018). An important factor seems to be how a beverage is actually consumed. For example, drinking through a straw that rests on the palate may reduce erosion by causing the liquid to bypass the teeth (American Dental Association, 2021). alcoholism, and pregnancy (hyperemesis gravidarum), may also contribute to dental erosion (American Dental Association, 2021). Increased salivary output before regurgitation is not a feature of GERD because the hypersalivation usually associated with vomiting is absent with this condition (Burgess, 2018). In fact, individuals with GERD have a low salivary flow and are often dehydrated (Delgado & Olafsson, 2019). Hypersalivation, which might minimize erosion, usually precedes vomiting as a response to stimuli such as self-induced vomiting among those with eating disorders or among those with chronic alcoholism disorders (Marieb & Hoehn, 2018). The pathogenesis of dental erosion is considered to be of multifactorial origin and includes mechanical forces and stresses such as attrition that are exerted upon the teeth (Delgado & Olafsson, 2019; Rappeport & Coleman, 2018). Attrition is the term used to describe the wear of the teeth without the presence of another material such as intrinsic or acidic substances, while erosion is used to describe the loss of tooth structure via a chemical process without bacterial involvement. The critical pH at which the hydroxyapatite component of enamel begins to dissolve is 5.5, with many soft drinks and sports drinks having pH levels less than this value (Touyz & Nassani, 2018). There is more loss of enamel from erosion followed by attrition, which is attributed to the reduced resistance of enamel that is softened by acids and then is subjected to the forces of attrition (Rappeport & Coleman, 2018). Intrinsic erosion can result from repeated vomiting, which is frequently associated with bulimia anorexia and alcoholism (Sengupta, 2018). The etiology of tooth erosion includes chronic, excessive vomiting as exemplified in patients with eating disorders, such as anorexia nervosa or bulimia (American Dental Association, 2021; Mitrani, 2019). It is estimated that dental erosion is eight times more common in patients with eating disorders compared to those without eating disorders (Johansson et al., 2017). With chronic, frequent vomiting, gastric acids, with a pH level between 1 and 3 (Santhiya et al., 2019) repeatedly rise up to the oral cavity and come in contact with the teeth. Long- term vomiting-related erosion typically affects the palatal surfaces of the maxillary teeth (Davis, et al., 2019).
PATIENT ASSESSMENT
To prevent the progression of erosion, it is important to detect this condition as early as possible. Dentists must be aware of the clinical appearance and possible signs of the progression of erosive lesions and their causes to take timely preventive and, if necessary, therapeutic measures. The clinical examination has to
be done systematically, and a comprehensive case history should be undertaken to ensure that all risk factors are revealed. Given the multifactorial nature of dental erosion, a formal protocol for assessment of patients who present with tooth surface loss can facilitate diagnosis.
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