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Prevention and control of dental erosion by professionally applied treatment

  • John A. Kaidonis
  • Poppy M. Anastassiadis
  • Dimitra Lekkas
  • Sarbin Ranjitkar
  • Grant C. Townsend
  • Bennett T. Amaechi
Treatment
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Abstract

Dental erosion is a type of tooth wear that occurs when the tooth is exposed to acids. It can be prevented by elimination or reduction of the acid challenge. Prevention should also aim at the remineralization of softened enamel by the enhancement of saliva remineralizing function through the use of fluoride formulations. The use of professionally applied products for the prevention and control of dental erosion should be a part of an overall preventive management program that includes home management by the patient. Each management plan needs to follow a preventive philosophy that is tailor-made for the patient. There is a plethora of products available for erosion management, each with their specific formulations and different concentrations. However, the availability of the products as well as their generic names varies in different parts of the world. Although examples of specific products will be mentioned in this article, the emphasis will be on general methods with reference to generic products in order to guide management.

keywords

Erosive toothwear Acid erosion Erosion prevention Surface protection Erosion control 

Quick reference/description

Dental erosion is a type of tooth wear that occurs when the tooth is exposed to acids. It can be prevented by elimination or reduction of the acid challenge. Prevention should also aim at the remineralization of softened enamel by the enhancement of saliva remineralizing function through the use of fluoride formulations.

The use of professionally applied products for the prevention and control of dental erosion should be a part of an overall preventive management program that includes home management by the patient.

Overview

Following are the different options available for prevention and control of dental erosion:

Treatment

Advantages

Disadvantages

Remineralization methods for softened tooth surfaces

Professionally applied fluorides

Gels and foams

Remineralizes softened eanamel

Slows demineralization process

Only effective in presence of calcium and phosphate ions

Fluoride varnishes

More effective remineralization

Extends the physical presence of fluoride

Suitable for young patients below 10 years of age

Uncertain long-term effects

Professionally applied calcium-containing technologies

Recaldent (CPP-ACP) technology

Effective remineralization

Safe

Not recommended for patients with milk protein allergy

Tri-calcium phosphate (TCP) technology

Effective remineralization

None

Tooth surface protection (prophylactic coatings)

Surface protective coatings with remineralizing potential

Provides instant relief of hypersensitivity

Provides a temporary barrier to subsequent acid challenge

Low viscosity allows it to flow easily on surfaces

Moisture tolerant

Effective remineralization

Limited longevity

Surface protective coatings without remineralizing potential

Eliminates hypersensitivity immediately

Provides a temporary barrier to subsequent acid challenge

Does not remineralize the teeth

Surface protection using bite-guards

Protects teeth during acid challenge

Requires patient compliance

Materials/instruments

  • Etchant (orthophosphoric acid)

  • Close-fitting trays

  • Salivary ejector

  • Brush

  • Gauze

  • Cotton rolls

  • Mixing slab

Procedure

TDental erosion can be prevented by elimination or reduction of the acid challenge. Different methods are used for prevention and control of erosion, and their selection depends on the patient case. Remineralization of the tooth surface and tooth surface protection are the widely used methods.

I. Remineralization methods for softened tooth surfaces

Different approaches to remineralization of softened tooth surfaces and for slowing the demineralization are:

Professionally applied fluorides

Gels and foams
Professionally applied fluorides are usually high concentration neutral fluorides (e.g., 2% NaF) that can be easily dispensed in disposable trays as either gels or foams (Table 1). Foams require less material than gels to supply the same amount of fluoride.
Table 1

Examples of products that can be used professionally for the prevention and control of dental erosion

Generic product and name

Details

Company

Neutral fluoride

 Denti-care pro-foam

2% neutral sodium fluoride foam

Medicare (US), (CAN)

 Denti-care pro-gel

2% neutral sodium fluoride gel

Medicare (US), (CAN)

 Nupro neutral fluoride gel

2% neutral sodium fluoride

Dentsply (AUS)

 Neutra foam

2% neutral sodium fluoride

Oral B (US)

 Neutracare gel

1.1% sodium fluoride

Oral B (US)

APF

 Nupro acidulated phosphate fluoride foam

1.23% APF

Dentsply

 Foam

1.23% APF

Germiphene

 Ultra control foam

1.23% APF

Waterpik (UK) (EUR)

 One minute topical fluoride foam

1.23% APF

Laclede (US), (AUS)

Stannous fluorides

 Pro-health toothpastes

1450 ppm F (stabilized stannous fluoride 1100 ppm, 350 ppm sodium fluoride and sodium hexametaphosphate)

Oral B (AUS)

 Crest pro-health toothpastes

0.454% stannous fluoride

Crest (US)

 Gel Kam

1000 ppm stannous fluoride

Colgate (AUS)

 Fluorigard gel toothpaste

1000 ppm stannous fluoride

Colgate (AUS)

Fluoride varnishes

 Duraphat

Sodium fluoride varnish, 22,600 ppm fluoride

Colgate (AUS)

 Cavity shield

5% sodium fluoride varnish

3 M (US)

 Profluorid Varnish

5% sodium fluoride Varnish

Voco (UK), (USA), (AUS)

 DuraShield Varnish

5% sodium fluoride varnish

Sultan Healthcare (EUR), (CAN), (US)

 Nupro

5% sodium fluoride varnish

Dentsply International

CPP- ACP

 Tooth Mousse

Recaldent

GC (AUS), (EUR)

 Tooth Mousse Plus (containing fluoride)

Recaldent with 900 ppm fluoride

GC (AUS), (EUR)

 MI Paste

Recaldent

GC (US)

 MI Paste Plus (containing fluoride)

Recaldent with 900 ppm fluoride

GC (US)

 MI Varnish

5% sodium fluoride varnish with recaldent

GC (US)

TCP

 Clinpro White Varnish

5% sodium fluoride with tri-calcium phosphate

3 M ESPE (AUS), (EUR)

 Vanish Varnish

5% sodium fluoride with tri-calcium phosphate

3 M ESPE (US)

 Clinpro Tooth Crème (toothpaste)

950 ppm fluoride with TCP

3 M ESPE (AUS), (EUR)

ACP

 Enamel Pro Varnish

5% sodium fluoride with Amorphous Calcium Phosphate

Premier (US)

Directions for fluoride gels and foams:
  • Prophylaxis of the teeth is not needed while using fluorides.

  • Close-fitting trays constructed by thermoforming machines should be used. The amount of fluoride dispensed should only cover the tray surface and should not exceed 2 milliliters (ml) in total.

  • It should be applied for about 4 min with the excess expectorated for about 30 s after the trays are removed. A salivary ejector should be used during the procedure.

  • The patient should be advised not to eat or drink for 30 min after application.

The ‘probable toxic dose’ should not be exceeded. The measure of 5 mg/kg for fluoride of body weight per day, and age recommendations must be followed (follow state therapeutic guidelines).

Fluoride varnishes

These are high-concentration fluorides (e.g., 5% NaF). They provide more effective remineralization as they are in contact with the tooth surface for longer time, allowing more calcium and phosphate from saliva to be utilized.

Directions for varnish application:
  • Prophylaxis of the teeth is not needed.

  • After mouth is dried, varnish is applied manually with a brush. It sets when in contact with saliva.

  • The patient is advised not to eat or drink for 30 min after application and should not brush until the following day.

Professionally applied calcium-containing technologies

Recaldent (CPP-ACP) technology

Recaldent technology (i.e. CPP-ACP: casein phosphopeptide–amorphous calcium phosphate) include calcium and phosphate that helps in remineralization. The calcium is stabilized by the protein CPP, preventing precipitation during storage within the dispensing tube. It is available as patient-applied pastes, such as Tooth Mousse Plus (GC Australia) or MI paste Plus (GC America) and professionally-applied varnish, such as MI varnish (GC America; GC Australia).

MI Varnish is a 5% sodium fluoride varnish incorporating Recaldent (CPP-ACP). It can be used as spot application, particularly over eroded areas or throughout the mouth and supplemented with the patient-applied pastes for home application.

Directions for MI Varnish application:
  • Prophylaxis is not recommended and the teeth should not be dried.

  • Apply the varnish directly to the tooth surfaces with a brush.

  • The patient should be asked not to eat or drink for 30 min after application.

Tri-calcium phosphate (TCP) technology

For effective remineralization, tri-calcium-phosphate is bio-actively protected from fluoride to prevent premature reaction and instant precipitation during storage within the dispensing tube. Following intraoral application, the protective coating is dissolved away by saliva, so that TCP and fluoride become bioavailable for remineralization. This product is available as patient-applied toothpaste, such as tooth crème (3 M oral care, Asia) or Clinpro 5000 (3 M oral care, USA) and professionally applied varnish, such as Vanish varnish (3 M oral care, USA).

Vanish varnish is a 5% sodium fluoride varnish incorporating TCP. It can be used as spot application, particularly over eroded areas or throughout the mouth and supplemented by the patient-applied toothpaste for home application.

Directions for MI Varnish application:
  • Prophylaxis is not recommended and the teeth should not be dried.

  • Apply the varnish directly to the tooth surfaces with a brush.

  • The patient should be asked not to eat or drink for 30 min after application.

II. Tooth surface protection (prophylactic coatings)

Surface protective coatings with remineralizing potential

Glass ionomer cements (GIC) and resin-modified glass ionomer cements (RMGIC) are used as protective coverings on eroded tooth surface to prevent further erosion.

To maximize their remineralizing potential of GIC and RMGIC, some manufacturers have added calcium and phosphate using CPP-ACP, TCP or ACP technologies.

Directions for applying:
  • Prophylaxis is required to remove any pellicle (biofilm) that may inhibit chemical adhesion.

  • The tooth surface should be conditioned to clean and prepare the surface for ion exchange. Then, the conditioner is washed and the tooth surface is dried but not desiccated.

  • Mix the material on a pad and then apply a thin layer evenly to the tooth surface with a microbrush.

  • Then, it is light-cured. Some rely on heat from the curing light to speed up curing (e.g., Fuji VII, Fuji VII EP) while others based on RMGIC rely on photo-initiators to cure the product.

  • To protect the product and add to the longevity of the material, a hard covering is applied over the cured surface. This provides a more durable surface barrier that resists wear (e.g., G-coat Plus: nano-filled, light-cured coating; GC International).

Surface protective coatings without remineralizing potential

These surface coatings do not have remineralization potential. When applied directly onto eroded tooth surfaces, they form a barrier that resists an acid challenge and obturates open dentinal tubules. This immediately eliminates hypersensitivity. These are resins that may contain some filler content and are similar to fissure sealants or typical adhesives.

G-Coat Plus™ (GC International) is a nano-filled self-adhesive coating, the main purpose of which is to give protection and longevity to glass ionomer cements and resin composites. It is light-cured over glass ionomer cements and resin composites in order to make these materials more durable (Fig. 1). By thinly laminating the surface, the material adds fracture toughness, wear resistance, acid resistance and longevity to restorations from 6 months and up to 2 years.
Fig. 1

Very active erosion with hypersensitivity on the buccal aspect of teeth 44 and 45. There is enough room for a thin layer of GIC or RMGIC surface covering, topped with G-Coat plus to add to the longevity of the initial coating

However, G-Coat Plus™ can also be applied directly over eroded dentin. It bonds to dentin, reduces hypersensitivity and provides protection against the subsequent acid challenge.

For bonding to enamel, the surface needs mild etching with orthophosphoric acid before the G-Coat plus is applied. One-step adhesives (Table 2) can be used on both the enamel and dentin prior to the placement of a more durable coating such as G-Coat Plus.
Table 2

Examples of products that can be used as prophylactic surface coatings in uncontrolled erosion

Generic product

Name

Details

Company

GIC

Fuji VII

Surface protection

GC (AUS)

Fuji Triage

Surface protection

GC (US) (EUR)

RMG1C (varnish)

Clinpro XT

Surface protection

3mESPE

GIC (with CPP-ACP)

Fuji VII EP

Surface protection

GC (AUS)

RMGIC (with TCP)

Clinpro White Varnish

Surface protection

3 M ESPE

GIC (with ACP)

Riva Protect

Surface protection

SDI (AUS)

Nano-filled light cured self-adhesive

G-Coat Plus

Surface and GIC protector

GC (AUS)

Single step tooth adhesive

G-Aenial Bond

Surface protection (add surface resin coating on top)

GC (AUS)

Single step tooth adhesive

Scotchbond Universal

Surface protection (add surface resin coating on top)

3 M ESPE

Resin

Seal & Protect™

Surface protection

Dentsply, Weybridge, UK

Resin

Optibond Solo™

Surface protection

Kerr Corporation, USA

Resin

Fissure sealant

Surface protection

 

Highly filled resin

Pro Seal

Surface protection

Reliance, USA

Highly filled resin

BisCoverLV

Surface protection

BISCO, Schaumberg, III

Highly filled resin

Opal Seal

Surface protection

Ultradent, Salt Lake city, Utah, USA

Highly filled resin

SeLECT™ Defense surface sealant

Surface protection

Element34 Technology, TX, USA

Surface protection using bite-guards/splints/nightguards

Bite-guards can be worn during exposure to an acidic challenge. The inner tooth surface of the guard should be coated with a small amount of sodium bicarbonate suspension or milk of magnesia to neutralize any acidic substance pooling inside.

Mouth guards can be used by:
  • Patients suffering from gastroesophageal reflux disease (GERD)

  • Patients suffering from eating disorders should wear it while vomiting or purging

  • Professional swimmers

  • Workers facing occupational exposure to erosive acid

Pitfalls and complications

  • The low pH of the APF (acidulated phosphate fluoride) is contra-indicated in patients who have teeth restored with glass ionomer cements and with indirect ceramic restorations.

  • Use of products containing HEMA (2-hydroxyethyl methacrylate) is contraindicated over dentin.

  • Fluoride is only effective when other elements (e.g., calcium and phosphate ions) also co-exist in the correct proportions to produce effective remineralization.

  • The resilient coatings can also prevent or limit fluoride release to the adjacent teeth and restrict some fluoride benefits.

Notes

Acknowledgement

Funding was provided by University of Texas System.

Further reading

  1. 1.
    Kaidonis JA, Anastassiadis PM, Lekkas D, Ranjitkar S, Amaechi BT, Townsend GC (2015) Prevention and control of dental erosion: professional clinic care. In: Amaechi BT (ed) Dental erosion and its clinical management. Springer, Cham, pp 151–168.  https://doi.org/10.1007/978-3-319-13993-7_9 CrossRefGoogle Scholar
  2. 2.
    Amaechi BT, Higham SM (2005) Dental erosion: possible approaches to prevention and control. J Dent 33(3):243–252CrossRefPubMedGoogle Scholar
  3. 3.
    Lussi A, Ganss C (2014) Erosive tooth wear: from diagnosis to therapy. Monographs in oral science. Karger, BaselGoogle Scholar
  4. 4.
    Kaidonis JA (2012) Oral diagnosis and treatment planning: part 4. Non-carious tooth surface loss and assessment of risk. Br Dent J 213(4):155–161CrossRefPubMedGoogle Scholar
  5. 5.
    Hannig M, Hannig C (2014) The pellicle and erosion. In: Lussi A, Ganss C (eds) Erosive tooth wear: from diagnosis to therapy. Monographs in oral science, 2nd edn. Karger, Basel, pp 206–214Google Scholar
  6. 6.
    Huysmans M-C, Young A, Ganss C (2014) The role of fluoride in erosion therapy. In: Lussi A, Ganss C (eds) Erosive tooth wear: from diagnosis to therapy. Monographs in oral science, 2nd edn. Karger, Basel, pp 230–243Google Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2017

Authors and Affiliations

  1. 1.School of Dentistry, Faculty of Health SciencesThe University of AdelaideAdelaideAustralia
  2. 2.Department of Comprehensive DentistryUniversity of Texas Health Science Center at San AntonioSan AntonioUSA

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