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Medical History
Initial evaluation begins with a thorough medical history review, including a listing of all prescription and non-prescription medications and supplements.  Items that are relevant to the problem of erosion include medications that may cause salivary hypofunction and those used to treat GERD.  The reader is referred to excellent articles that address this cause of decreased salivary flow rate.^53,54  Acidic medications or supplements such as Vitamin C and the method of ingestion should be noted.

Figure 10.
Diseases that cause salivary hypofunction are also important to note.⁵⁵  Sjogren's syndrome is an autoimmune condition in which chronic inflammation of the salivary and tear glands cause dry mouth and eyes.  A history of radiation therapy of the head and neck also leads to non-reversible oral dryness.  Lack of mechanical clearance and buffering of acids by saliva can increase the risk of erosion regardless of the source of the acid. In addition, a patient may use acidic beverages in efforts to stimulate residual salivary flow and keep the mouth moist.  Together with diminished salivary flow, this compounds the risk of erosion. Figure 10 illustrates attempts of the dentist to repair erosion in a patient with Sjogren's syndrome.  The patient sipped an acidic sugarless drink all day to maintain oral moisture until he was made aware of the cause of his erosion.  Arrow "A" points to a restored surface placed to protect the dentin.   Arrow "B" points to exposed dentin.

Frequent use of over-the-counter medications such as antacids may indicate the presence of gastroesophageal reflux disease (GERD).  The patient may not realize there is any relevance to the teeth and fail to mention it.  However, as described previously, there is a significant association between the presence of GERD and erosion.  Therefore, it is important to ask about the presence of symptoms (Table 3) and note if the patient is taking medications for this condition.

Figure 11.
Several important medical history items which require sensitivity to elicit are frequency of vomiting associated with eating disorders or alcoholism.⁵⁶  An uncommon habit that bears mentioning for sake of completeness is rumination.  Rumination is the chewing of regurgitated gastric contents before re-swallowing.  This habit has been described in highly motivated professionals as a response to stress as well as institutionalized individuals with learning difficulties.^57,58

Dietary Questionnaire
Many studies investigating risk factors for erosion have identified higher intake of acidic foods and beverages in individuals with erosion compared to those without.  Therefore, a dietary questionnaire focused on acidic foods and beverages should be completed by the patient.  In addition to frequency of intake, the manner of ingestion should be included.  Acidic beverages which are sipped over a long period of time or held in the mouth for extended periods can cause considerable damage to the teeth.

Figure 12.

Figure 12 illustrates erosion of the left side mandibular molars of a 20-year old female who habitually enjoyed holding a cola beverage in this area for several minutes before swallowing.  Other parts of the dentition were not affected. It has been suggested that using a straw to drink acidic beverages may minimize possible erosive effects by allowing the bulk of the fluid to bypass the teeth.²³

It is important to include intake of alcohol as many alcoholic beverages such as wine and beer are acidic.  Beverages used in mixed drinks are also generally very acidic. High levels of consumption may also indicate alcoholism, which increases the risk of frequent vomiting and GERD.

Dental History
A history of jaw parafunction and bruxism may increase the possibility of attrition in addition to erosion.  Figure 11 shows erosion (arrow) secondary to day-long sipping of a cola drink in a patient who presented initially with a complaint of muscle pain related to bruxism.  Her acidic oral environment most likely contributed to the extensive occlusal attrition.  To help determine if a bruxism habit exists, ask whether the patient makes grinding noises during sleep and whether he or she experiences morning jaw muscle tenderness or fatigue.⁵⁹

To determine the extent that toothbrushing habits may be contributing to tooth wear, information about frequency and method of brushing, as well as the type of dentifrice used, should be obtained.  Brushing immediately after the consumption of acidic foods, or vomiting may also accelerate tooth structure loss because the enamel is softened by the presence of acid.  As enamel thins from erosion, the teeth may appear more yellow as the underlying dentin shows through.  A patient may attempt to whiten the teeth by more rigorous brushing with a toothpaste that is more abrasive (e.g., toothpaste advertised to smokers), compounding the erosion with abrasion.  Fluoride use should be assessed.

Occupational/Recreational History
Current industrial safety standards have lessened the occurrence of erosion associated with environmental hazards in the work area.  However, individuals who swim frequently in chlorinated pools should obtain information about pool water acidity.  The character of the patient's work environment, or hobbies such as wine-tasting should be included in the historical inquiry.

Head and Neck/Oral Examination
Upon conducting a head and neck exam, note any signs of tenderness or hypertrophy of the masticatory muscles which may indicate a bruxism habit.⁵⁹  Signs of chronic alcoholism such as enlarged superficial capillaries in the facial skin (spider angiomas) or frequent breath odor of alcohol should be noted.  Enlargement of the parotid salivary glands may be a sign of Sjogren's syndrome, chronic alcoholism, or bulimia.

Mucosal signs of decreased salivary flow include inflammation, dryness and inability to express saliva from gland orifices.⁶⁰  However, although decreased salivary flow has been associated with erosion in some studies, it is not uncommon to find normal flow rates in patients with erosion.  Therefore, the oral mucosa is likely to appear normal.  However, a prominent linea alba of the buccal mucosa, and lateral tongue indentations may indicate a bruxism habit.

Figure 13.

Caries is generally an uncommon occurrence in patients with erosion.  Additionally, teeth with erosion do not tend to retain plaque.  A frequent finding is preservation of a cuff of enamel within the gingival crevice.  Figure 13 illustrates this phenomenon, which may to be due to protection of the enamel by the gingival crevicular fluid.

The location, degree and type of tooth surface loss should be documented by careful description.  Several indices of measurement have been described in the scientific literature and are important for epidemiological studies.^2,6  However, in managing a patient in a practice over a number of years, it may be easier and more accurate to document tooth wear by taking impressions and making models of the patient's teeth (Figure 14).  The models can then be retrieved later for visual comparison with current models at various times of reevaluation.  Intraoral photos are also useful for documentation of erosion and monitoring of success of preventive measures.  Comparison of teeth in radiographs may also reveal loss of tooth surface.  Figure 15 is a radiograph of the same patient depicted in Figure 1.  Taken at age 14, the radiograph shows the thinned enamel of #19 and #20 compared to #18, which erupted more recently and had less exposure time to acids.  The only possible risk factor for erosion was a very low salivary buffer capacity.

Figure 14. Study casts of eroded teeth. (Courtesy, Dr. Douglas Ramsay, University of Washington)

Figure 15. Radiograph of eroded teeth.

Salivary Function Assessment
The subjective sensation of oral dryness may not reflect actual salivary gland function.⁶¹  Therefore, it is important to assess salivary flow rate when evaluating patients with erosion.  This measurement can be conducted in the typical dental office by quantifying the amount of saliva collected over several minutes, expressed in milliliters per minute, both under non-stimulated and stimulated conditions (e.g., gum-chewing).⁶⁰

Although low buffer capacity of saliva has been associated with erosion, the utility of measuring salivary pH and buffer capacity in these patients has not yet been validated but remains an important area for further investigation.  A commonly used method for measuring buffer capacity in European studies (Dentobuff, Orion Diagnostica) is available for research purposes only in the US.

 

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