Received: 19 November 2020 Accepted: 28 December 2020

DOI: 10.1111/jerd.12706

REVIEW ARTICLE

Contemporary diagnosis and management of dental erosion

Terence Donovan DDS1 | Caroline Nguyen-Ngoc DMD, MS2 |

Islam Abd Alraheam DDS, MS3 | Karina Irusa BDS4

1
Division of Comprehensive Oral Health,
University of North Carolina at Chapel Hill,
Chapel Hill, North Carolina, USA
2
Department of Restorative Dentistry,
Universite de Montreal, Montreal, Quebec,
Canada
3
Department of Conservative Dentistry,
University of Jordan, Amman, Jordan
4
Advanced Education in Operative Dentistry
and Biomaterials, University of North Carolina
at Chapel Hill, Chapel Hill, North Carolina, USA
Correspondence
Karina Irusa, Resident Graduate Program in
Operative Dentistry and Biomaterials,
University of North Carolina at Chapel Hill,
385 S Columbia St, Brauer Hall, Room
429, Chapel Hill, NC 27599, USA.
Email: fkarina@live.unc.edu
Abstract
Objective: This article is aimed at providing an overview of the topic of erosive
tooth wear (ETW), highlighting the clinical signs, diagnosis, and management of
dental erosion.
Overview: With the increased prevalence of ETW, it is important that oral health
professionals are able to recognize the early signs. Early clinical signs of dental ero-
sion are characterized by loss of enamel texture, a silky glossy appearance, and some-
times a dulling of the surface gloss, referred to as the “whipped clay effect, cupping,
and restorations ‘standing proud’.”
The progression of ETW should be monitored by means of diagnostic models or clini-
cal photographs. ETW can be as a result of acid attack of extrinsic or intrinsic origin.
Conclusion: There is an increase of ETW that is being recognized by the profession.
The first step in diagnosing and management is to recognize as early as possible that
the process is occurring. At that point a determination of whether the primary etiol-
ogy is either intrinsic or extrinsic should be made. If these findings are confirmed,
appropriate prevention, and management strategies can be adopted followed by
appropriate restorative therapy.
Clinical Significance: The prevalence of ETW continues to increase. It is there-
fore important that oral health care providers have a better understanding of
the etiology, pathophysiology, and management of this condition. This review
aims to provide the guidelines for diagnosis and management of dental
erosion.

KEYWORDS
dental erosion, erosive potential, erosive tooth wear, extrinsic, intrinsic

1 | I N T RO DU CT I O N regarding periodontal disease and oral health care professionals spend

In recent years, the dental profession has become increasingly aware
of the problem of erosive tooth wear (ETW). Through the strategy of
community water fluoridation, fluoride containing toothpastes, and
patient education, caries rates have reduced considerably for a broad
segment of the population. The public has considerable knowledge
a significant portion of their working time attempting to prevent peri-
odontitis. ETW is a significant problem for increasing numbers of
patients and it is important that oral health professionals are trained
to recognize the early signs of ETW so that effective strategies and
protocols can be implemented to prevent its progression and reduce
the need for extensive restorative dentistry.

78 © 2021 Wiley Periodicals LLC wileyonlinelibrary.com/journal/jerd J Esthet Restor Dent. 2021;33:78–87.

DONOVAN ET AL. 79

2 | PREVALENCE 4 | EARLY SIGNS OF DENTAL EROSION

The prevalence of dental erosion, a form of tooth wear that can be Diagnosis, prevention, and management of dental erosion relies
found in both primary and permanent teeth, is significant. In children heavily on the dentist's ability to accurately identify clinical signs and
and adolescents, systematic reviews report a good amount of data, relevant etiologies to assist in developing adequate management
while studies are more scattered in adults because of heterogeneity strategies. Early diagnosis of the erosive process can be difficult, but
of the methodology used. However, there is a consensus that the frequent exposure to acidic challenges can eventually lead to perma-
severity of dental erosion increases with age.1,2 This trend can be nent and clinically detectable loss of dental hard tissue.19 This process
found in different parts of the world. For example, the prevalence of appears to progress at a much faster rate than caries as a surface
dental erosion found in Israel increased from 36.6% between the ages lesion.20 Clinical signs of rapid progression may be dentin hypersensi-
3
of 15–18 to 61.9% between the ages of 55–60. Similarly, prevalence tivity and absence of staining of the lesion. However, most patients
in Chinese adults was 67.5% among 35–49 year-olds and 100% do not present with symptoms, especially when progression is slow
among 50–74 year-olds.4 The range of prevalence found in the litera- and reparative dentin has time to obliterate tubules. Sometimes, even
ture is very wide and can vary as much as 4%–100% in adults.5 Aside the most severe erosion cases leave the patients asymptomatic,
from the diverse methodologies used among existing studies making emphasizing once again the importance of dental practitioner's aware-
comparison difficult, major differences would be expected between ness and early detection.21,22
countries solely based on cultural and environmental factors. A
pan-European study found that an average of 29% of young adults
(18–35 years old) had dental erosion with 3% showing severe signs
of erosion with significant differences between countries.6 It is inter-
esting to note, however, that some authors have observed that the
adoption of a more Westernized diet and lifestyle in Asia is likely to
have an effect on dental erosion in all age groups.7 Numbers appear
to be similar in an American and Japanese study where prevalence
was 25% and 26.1%, respectively.7,8 A rise in prevalence and sever-
ity has also been observed especially in adolescents and young
adults in many European countries and the USA.3,6,9-11 Changes in
dietary habits in recent years, including a higher frequency of con-
sumption of newly marketed acidic foods and drinks may have
F I G U R E 1 An example of the “whipped clay effect.” Note the
mainly contributed to that phenomenon.12,13 Because dental erosion dull appearance of the enamel with absence of perikymata and
is an irreversible cumulative process during a lifetime, prevalence is erosion into the cervical dentin
expected to increase in the future if acidic dietary trends continue in
the same direction.

3 | E R O S I O N I N US S C H O O L
C U R RI C U L U M ?

A recent survey of US and Canadian dental school confirmed that the

inclusion of dental erosion in the curriculum remains questionnable.14
Results showed that although the topic is taught, only 15.3% of
respondents identified correctly all the clinical signs of dental erosion
and that 45.8% did not teach any type of tooth wear index for moni-
toring. Since etiology, risk assessment, and management are not simi-
lar to dental caries, it is debatable whether dental erosion will be
integrated into core cariology curricula as has been suggested.15,16
There is a need to establish clearer topics and requirements emphasiz-
ing the diagnosis and management of dental erosion in North America,
especially since the interpretation of tooth wear is often erroneously
associated with attrition and treated as such, when compared to the
Europeans.17 In fact, a recent survey of general practitioners in the US
showed that only 30.5% could correctly identify all the clinical signs
of dental erosion, although 86% felt competent to do so.18 FIGURE 2 An example of moderate cupping
80
F I G U R E 4 An example of cervical erosion lesions on teeth #8 and
9 caused by drinking diet cola and holding it in the muco-buccal fold
Early clinical signs of dental erosion are characterized by loss of
enamel texture, a silky glossy appearance and sometimes a dulling of
the surface gloss, referred to as the “whipped clay effect”23,24
(Figure 1). Other characteristic signs include cupping of cusps on the
occlusal surfaces and flattening of the occlusal structures (Figure 2). In
later stages, occlusal morphology can completely disappear with
hollowed out surfaces and restorations “standing proud” above adja-
cent tooth structures21,23,25-27 Figure 3). On smooth surfaces, convex
areas flatten or concavities appear with the width usually exceeding
the depth (Figure 4). Lesions are located coronal from the cemento-
enamel junction with an intact rim of enamel along the gingival mar-
gin, possibly due to plaque remnants acting as a diffusion barrier for
acids or the neutralization effect of slightly alkaline sulcular fluid. Pro-
gression can result in pseudo-chamfers at the margin of the eroded
surface.28
Initial enamel and dentin lesions are often difficult to differentiate
23,29
from abrasive lesions. However, wedge-shaped defects from
abrasion or abfraction usually have sharp margins coronally with cuts
at right angles into the enamel surface, and the depth usually exceeds
the width.28 Abrasion is caused by an abnormal mechanical process,
and aggressive oral hygiene habits (e.g., traumatic brushing or abrasive
toothpaste) is most often at fault.26,30 It is also important to distin-
guish defects caused by attrition, where the action of opposing teeth
DONOVAN ET AL.
F I G U R E 3 (A) and (B): Examples of
“restorations standing proud” with silver
amalgam (A) and composite resin (B)
produces matching polished wear facets on the occlusal or incisal sur-
faces.26 Lesions are typically flat, sharp bordered, and glossy.21,28
However, thorough information gathering about medical and dental
history is necessary to confirm causative factors of clinical
manifestations.
5 | BASIC EROSIVE WEAR EXAMINATION:
S C R E E N I N G TE S T F O R ER O S I V E
T O O T H WE A R
In order to monitor progression and management of dental erosion,
photographs, and diagnostic models (conventional or digital) should
be made periodically.24,31 To further raise awareness and aid practi-
tioners in screening and monitoring progression and severity of
ETW, wear indices have also been developed. These were designed
to be used both in private practice and for research purposes.32
Many research groups have developed their own tooth wear index,
however, making research in this field challenging to compare. They
are modified for each specific study according to study aims, and
may vary in their manner of assessment, scale, choice of teeth, and
other differing modalities.3 Hence, a workshop was conducted in
Switzerland to discuss the various dental erosion indices available,
and it was determined that a simple and standardized index is neces-
sary. The workshop proposed that the basic erosive wear examina-
tion (BEWE) be used for both the research field and dental
clinicians.29
The BEWE was developed and recommended in 2008 by Bartlett
et al and is a simple, reproducible and transferable scoring system for
recording clinical findings and assisting in the decision-making process
for the management of dental erosion.32 A sextant based exam is con-
ducted, where the surface of the tooth with the worst wear is graded
in each sextant, resulting in a calculated cumulative score which
allows risk and guidelines for management to be determined (Tables 1
and 2). A clinical study aiming to assess reliability of BEWE found that
although it slightly underscored moderate to severe wear, the exami-
nation gave very few false positives, predicting severe wear with a
sensitivity of 90.9% and a specificity of 91.5%.33,34 When comparing
scores between 2 examiners, reliability showed moderate agreement
DONOVAN ET AL. 81

T A B L E 1 Basic erosive wear examination - criteria for grading T A B L E 2 Basic erosive wear examination - risk levels as a guide
erosive wear32 to clinical management32

Score Criteria Risk Cumulative score of

level all sextants Management
0 No erosive tooth wear
1 Initial loss of surface texture None Less than or equal to 2 Routine maintenance and
observation
2 Distinct defect, hard tissue loss <50% of the surface area
Repeat at 3-year intervals
3 Hard tissue loss ≥50% of the surface area
Low Between 3 and 8 Oral hygiene and dietary
assessment, an advice,
routine maintenance, and
observation
and it was concluded by the authors that BEWE was an effective
Repeat at 2-year intervals
screening test for severe tooth wear, but because it is inherently sim-
Medium Between 9 and 13 Oral hygiene and dietary
ple, scores should be interpreted with some caution.33 To avoid diag-
assessment, and advice,
nostic uncertainties, BEWE does not distinguish between enamel loss identify the main etiological
and exposed dentin.32 A recent study further validated BEWE as a factor(s) for tissue loss and
screening tool by showing that sextant cumulative score provided a develop strategies to
eliminate respective impacts
good representation of tooth wear when compared to scores of all
Consider fluoridation measures
tooth surfaces.35
or other strategies to
increase the resistance of
tooth surfaces
6 | INTRINSIC VERSUS EXTRINSIC ETW Ideally, avoid the placement of
restorations and monitor
ETW can be due to extrinsic factors, intrinsic factors or a combination of erosive wear with study
casts, photographs, or
both. Extrinsic factors are usually related to dietary habits, lifestyle, occu-
silicone impression
pational hazards or acidic medications, and other drugs.36-38 Intrinsic fac-
Repeat at 6–12 months
tors on the other hand involve the introduction of gastric acids intraorally
intervals
at a rate that exceeds the buffering capacity of saliva.38,39 This occurs in
High 14 and over Oral hygiene and dietary
the following conditions: Gastroesophageal reflux (GERD), bulimia assessment, and advice,
nervosa, chronic alcoholism, and hyperemesis gravidum in preg- identify the main etiological
nancy.36-38,40 To assist clinicians identify the source of acid for proper factor(s) for tissue loss and
develop strategies to
management, locations of erosive lesions may be used as an indicator,
eliminate respective impacts
but should not be the sole factor in determination.41 Correctly identifying
Consider fluoridation measures
the source of the acid is achieved by a combination of both clinical exam-
or other strategies to
ination and comprehensive history taking. Extrinsic erosion typically pre- increase the resistance of
sents on labial surfaces of anterior teeth, buccal surfaces of posterior tooth surfaces
teeth, and occlusal surfaces posterior mandibular teeth.26 On the other Ideally, avoid restorations and
hand, intrinsic erosion tends to occur on the anterior maxillary palatal sur- monitor tooth wear with
study casts, photographs, or
faces, posterior maxillary and mandibular occlusal surfaces, and posterior
silicone impressions
mandibular buccal surfaces.26,27,30
Especially in cases of severe
Much like dental caries, not everyone is at the same risk for ETW
progression consider special
and various external and internal factors play an important role in care that may involve
susceptibility.18 restorations
A diet analysis is a useful diagnostic aid in the diagnosis of extrin- Repeat at 6–12 month
sic erosion caused by dietary factors. Frequent consumption of soft intervals

drinks, sports drinks and fruit juices with a low pH have been identi-
fied as significant causes of extrinsic erosion.37,40,42,43 Chewable vita-
min C tablets, some sweet snacks and sweet–sour candies have also
been found to have a significant erosive risk.44-46 Vegetarian diets or
excessive use of vinegar-based dressings has also been shown to
increase dental erosion risk.47,48
Thorough socio-economic history taking is essential in the diag-
nosis of extrinsic erosion. Some occupations have been associated
with a high incidence of dental erosion such as factory workers in
battery, fertilizer, and munition plants who are exposed to airborne
industrial acids.36
Intake of recreational drugs such as methamphetamine, cocaine,
and ecstacy has also been associated with dental erosion.47,48
Swimmers who have been frequently exposed to poorly chlori-
nated pools have also been linked to increased risk for dental erosion
due to low pH of the swimming pool water.36,49
82
In addition to clinical examination, diagnosis of intrinsic erosion
may be facilitated by conducting a thorough medical and social his-
tory. Diagnosis by elimination may be necessary in many cases.
Increased intra-abdominal pressure as a result of pregnancy or
obesity are risk factors for developing GERD.38 A relationship has also
been drawn between GERD and several chronic respiratory condi-
tions.50-52 Common symptoms of GERD in adults include presence of
an acid taste in the mouth, heartburn, persistent coughing, vomiting,
belching, halitosis, a feeling of a lump in the throat, stomach ache, sore
throat, choking spells, hoarseness of voice, excess salivation, and gas-
tric pain on awakening. Symptoms of GERD in children include diffi-
culty in sleeping, laryngitis, bronchitis, failure to gain weight, anemia,
feeding problems, asthma, irritability, and recurrent pneumonia.53 A
definite diagnosis of GERD should be made by a gastroenterologist
54
after conducting a 24 hour ph manometry test.
A diagnosis of bulimia or alcoholism may not be entirely straight
forward as getting the patient to admit to these habits is quite the
task. Often direct, closed-ended questions may be the only option for
example “For how long have you been vomiting?” Signs of bulimia
may include a fluctuation in weight while anorexic patients may
appear thin and emaciated.55 Other signs of eating disorders include
dry or cracked lips, parotid glad swelling, esophagitis, and burning
53
tongue. Physical signs of alcoholism include flushing and puffiness
of the face as well as spider angiomas on the skin.54
Diagnosis of parafunction is important as parafunctional habits
can accelerate the rate of ETW forming combination lesions which
56
may complicate the management protocol. Parafunction can be
diagnosed using a combination of a thorough history and clinical
examination. Masticatory muscles should be palpated for presence of
tenderness and the dentition should be examined for the presence of
key and lock wear facets. These facets, if present, should be recorded
and followed up by use of diagnostic models and photographs.
An enquiry should be made on the patient's oral hygiene habits
such as their toothbrushing frequency and method, type of dentifrice
used and use of topical fluorides.
An assessment of salivary flow rate, ph and buffering capacity
should be made as saliva plays a protective role in ETW by buffering
the oral environment during acid attacks. Palpation of the parotid
glands should be performed as enlargement is indicative of autoim-
mune disease, anorexia or alcoholism.54 Medical history should be
aimed at identifying intake of xerostomia inducing medications such
as diuretics, antidepressants, and asthma inhalers. A history of diabe-
tes mellitus, autoimmune diseases, radiotherapy, and chemotherapy
may also predispose patients to xerostomia.57
7 | CONTROL/PALLIATIVE PROTOCOL
Once the etiological factors for dental erosion have been established
it is paramount that these factors are controlled. Prevention and early
detection of ETW should be a primary goal for practitioners, as severe
stages of ETW can lead to aggressive and costly treatments. Patient
information and education is of paramount importance. Patient
DONOVAN ET AL.
education on behavior change is as important as stopping/slowing the
progression of ETW.
A multidisciplinary approach should be considered, especially if
the etiology of ETW is determined to be intrinsic.
Patients who are suspected to have GERD should be referred to
gastroenterologists for management. The treatment of GERD starts
with posture adjustment followed by dietary modification and the use
of antacids, proton pump inhibitors, or H2 receptor blockers.54 This is
done while the dentist continues to provide both preventive and
restorative treatment for the patient.
Psychological counseling referrals should be made in eating disor-
der patients and definitive restorative management should not con-
tinue until a green light has been given by the attending psychologist.
However because of the high recurrence rates of this disorder, the
consequences of a resumed purging habit on the definitive dental res-
torations should be discussed with the patient. Obtaining written con-
sent is important.55
In the case of bulimia or ETW due to dietary factors, the patient
should be advised to avoid brushing their teeth for 30 min after an
acid attack and to rinse their mouth with water, a sodium bicarbonate
rinse, fluoride rinse, or milk proceeding an acid attack as the dental
hard tissues are more susceptible to abrasion.36,43,58,59 In order to
decrease the abrasive forces, use of soft toothbrushes and toothpaste
with mild abrasivity should be advised. If medications significantly
affect the quality and quantity of saliva, discussions should take place
with medical providers to assess different strategies to decrease risk,
whether it be changing medications, dosage or frequency. To increase
salivary flow, sugar free or xylitol mints, and gums may also be used in
addition to pilocarpine.27 Fluoride varnish application as well as other
modes of fluoride therapy can also be introduced to enhance
remineralization of the dentition.54
As for extrinsic sources, referral to a registered dietician may be
recommended. A written diet diary should be prescribed to patients at
risk for the dental team to analyze. Dietary counseling can then be
personalized efficiently based on the diet analysis assessment. It is
suggested that 2 week days and a weekend be recorded to reflect the
patient's dietary habits as much as possible. Diet modifications can
then be recommended.26,27,60 Frequent consumption of acidic foods
and drinks, and some oral habits such as swishing or holding drinks in
the mouth, may exacerbate erosive potentials.27,30,54,57,59 Behavioral
management should also include the manner in which food is con-
sumed (chewed, sucked, dissolved). Elimination of certain foods or
decreasing contact time (e.g., use of a straw) may also be consid-
ered.26,42,61 Ultimately, the objective of controlling risk factors is to
stop the progression of ETW, assuming that the patient is compliant.
8 | DEFINITIVE PROTOCOL (ADDITIVE)
Once the etiology has been established and risk factors controlled,
restorative management can be considered. When there is no com-
promise to the existing tooth structure, resin sealants, or bonding
agents can be applied over the dentin. This may not only reduce
DONOVAN ET AL.
sensitivity for a limited time period but may also slow down the pro-
gression of ETW.27 Restorations should be conservative and additive
27
in nature, especially in mild and moderate lesions. Additive proce-
dures can involve both direct resin composite and indirect ceramic
partial coverage restorations.
In advanced lesions where loss of occlusal vertical dimension may
have occurred, more aggressive therapy to restore esthetics and func-
tion may be indicated. This includes full coverage crowns as part of an
extensive oral rehabilitation.62 Regular monitoring and evaluation of
ETW management should be done during recall visits.17
9 | S I L E N T G E R D / O B ST R U C T I V E S L E E P
APNEA
Patients presenting at the dental office with unexplained ETW are
often asymptomatic or oligosymptomatic in up to 25% of cases, and
“silent GERD” should be suspected.63,64 In subjects with severe ETW,
few experienced frequent symptoms, but 69% actually had abnormal
reflux when they were tested using both endoscopy and 24 h multi-
channel intraluminal pH-impedance measurements.64 If silent GERD is
left undiagnosed, it can lead to critical consequences such as pre-
malignant Barrett's esophagus or even esophageal adenocarci-
noma.65-67 Dentists play a critical role in such cases as they may be
the first to suspect this potentially life-threatening condition and
make appropriate referrals to a physician. On the other hand, prompt
referral to a dentist by physicians may save patients costly treatment
before ETW causes extensive damage to the dentition over time.68
Nocturnal reflux may play a major role in ETW severity since pro-
tective mechanisms during the day such as salivary flow, swallowing,
gastric emptying, and pressure of the upper esophageal sphincter are
decreased during sleep.65 There is an association between nocturnal
reflux and obstructive sleep apnea (OSA). Episodes of OSA stimulate a
reflex respiratory effort which leads to increased intraabdominal pres-
sure and decreased intrathoracic pressure therefore leading to acid
reflux in what Eskiizmir and Kezirian referred to as “a vicious cycle
between OSA and laryngopharyngeal reflux disease.” The incidence
of GERD in OSA patients is between 54% and 76%.69 Sleep related
GERD occurs more frequently during the lighter non-rapid eye move-
ment (first 2 hours of sleep) Episodes of nocturnal GERD last longer
than those of daytime GERD (15 and 2 minutes respectively).68
Miyawaki et al were able to demonstrate an association with both
GERD and OSA with bruxism. They found that there was an increase
in Temporalis muscle activity with a drop in esophageal ph.70
Diagnosis of OSA is reached by conducting a facility-based poly-
somnography (sleep studies). An overnight sleep study is the conven-
tional diagnostic test for diagnosing OSA. Full night polysomnography
studies have been recommended. Supervised facility based sleep stud-
ies over 1 or 2 nights are recommended for a diagnosis of OSA to be
made.71 It has been reported that OSA may predispose some patients
72
to nocturnal GERD. There is evidence that treatment of OSA using
continuous positive airway pressure (CPAP) improves nocturnal GERD
symptoms in 75% of patients, even in those without OSA.69,73
83
Mandibular advancement appliances have been shown to lead to suc-
cessful management of OSA in 82% of patients.74 Mandibular
advancement should however be conducted by properly trained den-
tist in the field of sleep medicine. A custom made device titrated from
an initial 50% of mandibular advancement is recommended and the
titration process can be carried out using pulse oximetry to establish
the maximum oxygen saturation achieved.75
If a diagnosis of OSA is made, it is recommended to manage the
sleep apnea first so as to control the acid reflux and reduce the
amount of medication the patient needs to manage the reflux. Man-
agement of GERD in OSA patients reduces the apnea–hypopnea
index. As dental practitioners the restoration of the dentition should
begin as soon as possible in GERD patients, even as they continue to
receive medical care so as to slow down the progression of ETW.
Even when the cause of ETW has not been ascertained, some form of
reconstruction may be required therefore as the dentist begins restor-
ative treatment it is important to perform the palliative phase
concurrently.76
10 | D E C I S I O N P R O T O C O L: D I A G N O S I S
A N D M A N A G E M E N T OF E R O S I V E
T O O T H WE A R
The basic decision sequence for diagnosing and managing ETW is to
first recognize that it is occurring. This can be accomplished by using a
screening tool like the BEWE or simply by doing a careful clinical
examination. The second step is to attempt to determine whether the
etiology of the ETW is intrinsic, extrinsic, or both. This is primarily
based on the history and the location and nature of the erosion
lesions as has been described previously. If the lesions suggest an
extrinsic etiology, expanding the history, and completing a diet analy-
sis should be done. Once the likely etiologic agents have been identi-
fied the patient should be counseled and suggestions given for
alternative less acidic foods and beverages and strategies to minimize
the erosive effects of the patient's diet.
If the pattern of ETW suggests that it is likely caused by intrinsic
erosion, the history should be expanded and a decision made as to
whether the primary etiology is an eating disorder or GERD. In both
cases, referral to medical colleagues is in order. Suspected GERD
patients should be referred to a gastroenterologist for upper-GI
endoscopy and pH monitoring. Patients suspected of suffering from
eating disorders must first admit that they are vomiting and then be
referred for psychological counseling. Definitive treatment should be
delayed until counseling has been successfully completed.
If a patient is diagnosed with silent GERD, he or she should be
referred to a gastroenterologist and the GERD controlled. Once the
GERD is controlled and the teeth are no longer at risk, the dentist
should then consider referring the patient to a neurologist for a sleep
study. The primary etiology for silent GERD is frequently undiagnosed
OSA. If a diagnosis of OSA is made, and it is controlled, either with
CPAP or a mandibular advancement prosthesis, prolonged medication
with proton-pump inhibitors can be avoided.
84
F I G U R E 7 Palatal erosion resembling pattern seen with bulimia
nervosa in a patient who drinks five glasses of champagne per night
11 | CLINICAL CASES
Patient #1 is an Asian male, age 42. He is a hairdresser who's chief com-
plaint is “My front bridge is loose.” The medical history is non-contributory.
He presents with severe cupping of the mandibular teeth and cupping and
palatal erosion of the maxillary teeth (Figure 5(A),(B)). He has silver amal-
gam restorations “standing proud” on teeth #18 and 19. The fixed partial
denture from teeth #7–10 is loose due to severe sub-gingival caries. We
suspected the lesions were intrinsic due to their location, and further
DONOVAN ET AL.
F I G U R E 5 (A) and (B): Examples of
severe cupping and palatal erosion in a
bulimic patient
F I G U R E 6 (A) and (B): Extrinsic
lesions due to chronic lemon sucking for
over 40 years (A) and mandibular bonded
ceramic restorations (B)
questioning revealed that he has suffered from an eating disorder (bulimia
nervosa) for many years. He was referred to a psychiatrist and therapy was
successful in stopping the chronic vomiting and the patient was restored.
Patient #2 is a 51 year old female lawyer with advanced ETW
(Figure 6(A),(B)). The diagnosis was easy because she admitted early in
the interview that she had damaged her teeth by sucking lemons
every day since she was 6 years old. The resulting lesions were on the
buccal and occlusal surfaces of the mandibular teeth and the buccal
and labial surfaces of the maxillary teeth. She requested an “adhesive”
restorative solution. She had ceased the lemon sucking habit so
the obvious extrinsic erosion was controlled. We decided to increase
the occlusal vertical dimension with porcelain laminate veneers on the
maxillary and mandibular anterior teeth to preserve all remaining
occlusal enamel on the posterior teeth for optimum bonding. The pos-
terior teeth were restored with partial veneer bonded ceramics.
Patient #3 was a 55 year old Caucasian woman that presented
with severe ETW on the palatal surfaces of her maxillary premolars
and incisors (Figure 7). The health history was non-contributory. The
lesion pattern suggested intrinsic erosion, but extended history taking
and a gastroenterology referral ruled out bulimia nervosa and GERD.
A diet analysis was conducted and revealed that she drank five glasses
of champagne/night and enjoyed holding the wine with her tongue in
the palate to feel the bubbles exploding against the palate. Cham-
pagne has a high erosive potential which explained the lesions. This is
an example of extrinsic erosion disguised as intrinsic erosion. The
patient was successfully counseled to discontinue drinking champagne
and restored appropriately.
DONOVAN ET AL.
F I G U R E 8 (A) and (B): Patient with
palatal erosion lesions due to
Gastroesophageal reflux, and labial
lesions on the maxillary and mandibular
anterior teeth. Note tooth #9 is not in
contact with the mandibular teeth in
protrusive
Patient #4 was a 23 year old recovering methamphetamine
addict who presented with significant erosion in the cervical third of
her maxillary incisors, exposing dentin in teeth #6–11 (Figure 1). The
erosion pattern was a classic example of the “whipped clay effect.”
She also had mild tetracycline staining and a mid-line diastema she
did not like. The erosion pattern suggested extrinsic erosion and was
confirmed when the patient admitted she drank huge quantities of
diet cola while she was under the influence of the drug. Because she
had been successfully counseled by her psychiatrist, an additive
mock-up was completed and she was restored with veneers on
teeth #5–12.
Patient #5 was a 33 year old male that presented with severe pal-
atal erosion of the maxillary incisors and premolars (Figure 8(A),(B)).
He said he suffered from sleep bruxism which was confirmed by his
spouse. The maxillary anterior teeth displayed excessive wear and the
patient had concluded that the wear was due to bruxism. However,
close examination of Figure 8(B) shows the patient in a protrusive
excursion. Note that tooth #9 is not in contact which leaves that diag-
nosis in doubt. Note also there is generalized erosion of the maxillary
anterior teeth and significant buccal erosion of the mandibular cuspids
and premolars. Thus, he had multiple lesions that appeared to be of
intrinsic origin, and also multiple lesions that would likely be of extrin-
sic etiology. Referral to a gastroenterologist confirmed a diagnosis of
chronic GERD. The history revealed he was a serious cyclist who rode
40–50 miles per day with a hydration pack filled with a sports
drink. Switching him to a sports drink with a pH above 7 (Heed,
Hammer Nutrition) controlled the extrinsic erosion. The gastroen-
terologist controlled the GERD with medication. He was eventu-
ally restored at an open vertical dimension with a full mouth
reconstruction.
12 | CO NC LUSIO NS
There is an increase of ETW that is being recognized by the profes-
sion. The first step in diagnosing and managing ETW is to recognize as
early as possible in the process that it is occurring. The early signs of
ETW have been described in this article. At that point a determination
of whether the primary etiology is likely either intrinsic or extrinsic
should be made. If these findings are confirmed, appropriate
85
prevention, and management strategies can be adopted followed by
appropriate restorative therapy.
DISCLOS URE
The authors do not have any financial interest in the companies
whose materials are included in this article.
This manuscript has been read and approved by all the authors
and the requirements for authorship as stated earlier in this document
have been met. Each author believes that the manuscript represents
honest work.
OR CID
Islam Abd Alraheam https://orcid.org/0000-0002-7293-3112
Karina Irusa https://orcid.org/0000-0003-3567-5860
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How to cite this article: Donovan T, Nguyen-Ngoc C, Abd
Alraheam I, Irusa K. Contemporary diagnosis and management
of dental erosion. J Esthet Restor Dent. 2021;33:78–87.
https://doi.org/10.1111/jerd.12706