Enamel wear: Causes and mechanisms

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What causes enamel erosion?

When tooth enamel is exposed to acids (from food, beverages or the stomach), it temporarily weakens and loses some of its mineral content. Saliva will help neutralize acidity, restore the mouth's natural balance and slowly harden the tooth enamel. However, because the tooth's recovery process is slow, if the acid attack happens frequently, the tooth enamel does not have the chance to repair.

Some fruit juices, wine and various fruits can be acidic and therefore potentially damaging to teeth. Acidic foods should not and cannot easily be avoided, but care needs to be taken as to how they are consumed.

It is not just what is consumed that causes enamel erosion, but also the way that acidic foods and drinks are held within the mouth. Holding or retaining acidic beverages in the mouth prolongs the acid exposure on the teeth, therefore increasing the risk of tooth enamel erosion. Swishing an acidic beverage, for example, can increase the beverage's contact with the tooth or teeth, increasing the risk of tooth erosion.

Tooth erosion can also result from intrinsic acids e.g. as a consequence of bulimia (vomiting) or indigestion (regurgitation/gastric reflux).

Enamel demineralization and remineralization cycles

Enamel undergoes natural dynamic cycles of remineralization and demineralization, normally favoring remineralization due to mineral-rich saliva, which helps neutralize acidity and reharden enamel.

However, exposure to gastric or dietary acids can demineralize and weaken enamel, causing it to lose some of its mineral content. Because the tooth’s recovery process is slow, if the acid attack happens frequently, the enamel does not have a chance to repair itself.

Enamel is equipped to respond to normal daily acid exposure. Brief periods of acid exposure trigger a demineralization process that reduces the mineral density of the enamel surface, thereby weakening it.1,2

Due to mineral-rich saliva, the enamel undergoes a natural process of remineralization to restore its mineral density and the enamel is strengthened again.1,2

Frequent exposure to acids, especially over long periods, can cause the remineralization process to become overwhelmed, leaving enamel weakened. In this state, enamel is at risk of irreversible wear.1,2

  • dual-protection-enamel

    Remineralization and demineralization process after 5-minute acid challenge3

    In vitro SEM images of enamel cross-sections show variations in mineral density3 Images taken from GSK Data on File 133333.

    SEM, scanning electron microscope

  • Remineralization and demineralization process after 20-minute acid challenge

    Remineralization and demineralization process after 20-minute acid challenge3

    In vitro SEM images of enamel cross-sections show variations in mineral density3 Images taken from GSK Data on File 133333.

    SEM, scanning electron microscope

Enamel erosion factors

Enamel erosion is a progressive condition

Enamel erosion is most commonly caused by a combination of chemical agents and physical wear.

Dietary acidic exposure results in the loss of calcium ions from the enamel surface layer.4,5 This weakens the tooth surface, leading to an increased susceptibility to mechanical abrasion such as tooth brushing.4,5

Everyday Behaviors That Put Enamel at Risk

The incidence of enamel erosion is on the rise, with 89% of American adults at risk.6 Recognizing early forms of erosion may be difficult, so discussing specific lifestyle habits with patients at risk of developing enamel erosion can help proactively identify it.

These risk factors include:7-9

  • Holding or “swishing” acidic drinks in your mouth
  • Snacking frequently
  • Consuming high levels of acidic fruits and juices
  • Eating disorders
  • Gastric reflux

Infographic adapted from Lussi et al. 2006

Patients’ enamel is at risk from the erosive effects of acidic food and drinks

Modern Dietary Habits Are Worsening enamel erosion

Around 46% of American adolescents are already exhibiting signs of this irreversible condition.10 This is due, in part, to the way acidic foods and drinks feature prominently in modern diets.

  • Coke

    Soda

    Up to 87% of US adults consume acidic foods and beverages everyday11

    Alcoholic drinks

    Great consumption of acidic drinks

    Alcoholic drinks are generally acidic and were increasingly consumed (both more often and in larger volumes) between 2001–2002 and 2012–2013 in the US12

    Smoothie

    Smoothies

    Some smoothies may have a pH < 5.513

  • Clock

    87% of adults are at risk of enamel erosion due to their diets.11 Children, adolescents and adults in America snack at least once and often several times a day.14

    Orange juice

    In 2012, fruit juice consumption in the US was highest in those aged 18–34 years15

Pronamel – helping protect your patients against enamel erosion

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Impact on patient quality of life

Find out about the impact enamel wear has on patients’ daily lives.

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Diagnosis

Explore an overview of diagnosing enamel wear.

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Management

Explore an overview of enamel erosion management.

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Enamel erosion

Find out more about enamel erosion.

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The Pronamel range

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