September 2007, Volume 3, Issue 8
Published by AEGIS Communications
Worn Out: How Americans Are Damaging Their Teeth
Robert Margeas, DDS
Today, health and fitness are emphasized in the media more than ever. Coupled with our celebrity-focused culture, this has helped to promote near impossible standards of beauty and health. Every year Americans dedicate countless hours and spend millions of dollars on their diet, fitness, and beauty regimens. However, many do not realize their commitment to staying trim and eating right may be damaging a very precious asset—their healthy smile. Common solutions to meeting American standards of beauty include exercising, eating healthy foods such as fruit and yogurt, consuming sports drinks, and using tooth-whitening treatments. All of these factors can contribute to tooth wear.
Acid Erosion and Tooth Wear
One of enamel’s biggest adversaries is the acid contained in foods and beverages. Acidic food and beverage consumption is on the rise, causing tooth wear and acid erosion to be of increasing concern in dental offices. Tooth wear can occur when the acidic byproducts of dietary sugars result in tooth demineralization caused by bacterial fermentation.1 For example, fruit, juice, and sports drinks have extremely low pH levels, and are therefore highly acidic, but are thought by many to be perfectly healthy. Even diet sodas can cause demineralization and tooth wear. Diet sodas actually have more acid in them than regular soda as the added acetic and carbonic acids make the drinks palatable because they lack sugar.2 In addition to soda, sport and energy drinks can cause significant acid erosion. Americans are heavy users of these products; in fact, Gatorade’s (Purchase, NY) retail sales surpassed $3 billion in the United States in 2005,3 far outselling Evian (Paris, France) bottled water sales of $500 million.4 Both energy drinks and popular caffeinated beverages such as coffee and tea are often consumed once per day or more, contributing to the increased instances of tooth wear.
What people are not consuming also can be a contributor to tooth wear. Many people do not consume enough water to properly rinse their teeth. Hydration aside, the importance of water lies in its ability to rinse sticky tooth surfaces and neutralize acidic residue. However, it takes 32 glasses of high-pH alkaline water to neutralize one glass of soda.1 Most patients do not drink enough water, and ironically turn to flavored (often acidic) beverages to stay hydrated. The Institute of Medicine sets general recommendations for water intake that state on average women should drink 91 ounces of water daily and men should drink 125 ounces daily to stay adequately hydrated.5 Dental professionals should recommend drinking water following consumption of acidic foods and beverages to help rinse teeth.
Even when they are well-hydrated, studies suggest athletes may be particularly at risk for tooth wear and acid erosion related to high and frequent intake of acid-containing sports drinks.6 The risk of dental erosion during exercise is believed to be particularly high because exercise often results in heavy breathing through the mouth and a reduced salivary secretion rate.6 While athletes are busy exercising, enamel may be exposed to acid without normal levels of saliva flow, potentially damaging the patient’s smile and contributing to caries or an increased likelihood of tooth wear. Excessive consumption of sports drinks only compounds this risk.
There are numerous ways patients can still look their best while protecting their teeth. To minimize the risk of diet-related acid erosion, ask patients to protect their teeth by taking a few easy steps:1
- Drink carbonated soft drinks and sweetened liquids in moderation.
- Drink fluoridated water and use toothpaste with fluoride.
- Swish out mouth with water to dilute sugar and acid.
- Use a straw to keep sugar and acid away from teeth.
- Never consume soft drinks or juice at bedtime or before or during exercise.
- Read product labels to avoid high-risk items such as sweetened drinks high in sugar.
- Get regular dental cleanings to remove plaque build-up.
- Use a remineralizing toothpaste, such as Sensodyne® ProNamel™ (GlaxoSmithKline, Research Triangle Park, NC) or Enamel Care® (Arm & Hammer, Princeton, NJ) at least twice daily.
Patients can protect teeth by watching what they consume and maintaining responsible hygiene habits, but often harmful hygiene habits require identification and correction by a dental professional. While patients may consider their overzealous brushing beneficial, it is doing considerable damage in the form of small lesions on tooth surfaces. Incorrect or aggressive brushing is most frequently identified as the cause of exposed dentin and resulting tooth surface loss, and thus an important causative factor for dentin hypersensitivity.7 Brushing faster or harder does not equal quality cleaning—in fact, less concentrated, fast-paced horizontal brushing may effectively erode tooth structure. Some patients may perceive that more forceful brushing removes more plaque; however, clinical trials have shown no significant correlation between brush force and plaque or stain removal.8 Patients sometimes brush more forcefully intending to remove stains, but alternately are creating lesions on tooth structure, leaving surfaces more susceptible to staining and sensitivity. Also, correlations have been found between dominant hand force and tooth wear. Tests have shown that dentin hypersensitivity on the left side of the dentition in right-handed people is most likely caused by a toothbrush, a toothbrush/toothpaste combination, or the combination of toothbrush use and erosion.9 Sensitivity symptoms are relatively easy to treat with appropriate products and mindful behavior, but cervical lesion damage from aggressive toothbrushing is more difficult.
The oral structure lost to abrasion cannot be replaced naturally and will eventually detract from the esthetic appearance of the mouth. Therefore, dental professionals may prevent the onset of tooth wear by noticing the following indicators:
- abrasive lesions that are linear in outline and follow the path of the etiologic agent. They appear initially as small, horizontal grooves across the facial (or, rarely, lingual) surface of the natural crown, near the cementoenamel junction;10
- the peripheries of the lesion are angularly demarcated from the adjacent tooth surface;10 or
- in later stages, the surrounding walls of the abrasive lesion make a V-shape by meeting at an acute angle axially.10
Dental professionals should advise the patient that all abrasive influences, such as toothbrushing, occur before any tooth-softening effects of erosion.7 However, common misconceptions result in frequent brushing immediately after meals. Whenever possible, brushing should occur before meals rather than after, and not within 2 to 3 hours of acid intake. Soft-bristled toothbrushes are recommended by many dental professionals and are as effective as hard-bristled brushes. In addition, professionals can recommend patients consider an electric toothbrush to further minimize potential for overaggressive brushing. Finally, patients should be warned that their aggressive habits may cause lesions leading to staining, sensitivity, and gingival recession. Additionally, they should know that they are not improving the physical appearance of their teeth, but in fact harming it. Furthermore, if aggressive toothbrushing is practiced over long periods of time, tooth and gum tissue will continue to deteriorate. Aggravating brushing techniques must be amended. The following tips may help to diagnose a patient who is at risk of abrasion:
- Ask a patient to bring in his or her current toothbrush for an examination of the filaments; splayed filaments may be a sign of overzealous brushing.8
- Ask a patient which hand is dominant, and examine if tooth wear correlates on the opposite side.
- Watch a patient brush his or her teeth, and, if necessary, demonstrate how to brush gently but effectively.
In addition to the high value placed on physical perfection, the rushed, goal-oriented American way of life can contribute to stress. The stressors that face many Americans cause up to 20% of adults and 18% of children to grind their teeth while awake.11 Eight percent grind their teeth while they are asleep, while most are unaware they are grinding.11 Habitually grinding teeth together is known as bruxism, a cause of surface wear. Dental professionals are often first to identify teeth affected by bruxism when symptoms appear. Early diagnosis is important, because bruxism may cause severe damage to teeth, broken dental work, jaw pain, headaches, sensitivity, and loose teeth, affecting almost every part of the mouth.
Although bruxism affects many parts of the oral cavity, a dental professional may be able to notice cuspal wear early. Early surface wear caused by tooth-to-tooth contact during mastication or parafunction is defined as attrition.12 The most prevalent sites for tooth wear attributable to attrition are the occlusal surfaces of the dentition. Age permits a certain degree of attrition, but if a patient has more rapid attrition than customarily associated with his or her age group, it may by related to pathological stress, and is probably a symptom of bruxism. In this case, it may be lifestyle-related and should be treated immediately. Custom-formed mouth guards can be prescribed for a bruxism patient who has difficulty changing his or her lifestyle. Lifestyle changes may include eliminating caffeinated beverages, as consuming caffeine is generally thought to increase the risk of grinding, among other harmful effects of caffeine.13
You can easily incorporate tooth wear assessment and diagnosis into each patient’s exam by looking for the following signs of stress-related bruxism:14
- excessive wear facets that are flat and shiny on the top of the back teeth, inconsistent with the age of the individual;
- thinning and chipping of the front teeth;
- abfraction with dentinal surface exposure;
- wedge-shaped erosions; and
- impressions of teeth as indentations on the sides of tongue.
Stress and related bruxism are only partly to blame for worn-out teeth. One of the most popular way people attempt to meet today’s standard of beauty is tooth whitening or bleaching. Tooth whitening treatments have increased in popularity by more than 300% in the last 5 years, according to the American Academy of Cosmetic Dentistry.15 Among the middle-aged, tooth whitening is the treatment of choice to improve physical appearance. According to a 2005 survey conducted by the American Academy of Cosmetic Dentistry, 70.2% of those inquiring about cosmetic dentistry are between 31- and 50-years-old and just want to look and feel better.16 Although it appears to be a "quick and easy fix" for teeth affected by smoking, or coffee or tea consumption, tooth whitening can contribute to painful sensitivity. Data suggests that up to 75% of tooth whitening patients may experience sensitivity.17 Byproducts of carbamide and hydrogen peroxide used in whitening pass though enamel and dentin into the pulp, causing nerve sensitivity. To reduce sensitivity, dental professionals should recommend that whitening patients use anti-hypersensitivity toothpaste like Sensodyne twice daily, 2 weeks before and 2 weeks during whitening treatment. Anti-sensitivity toothpaste may be a useful adjunct to the management of sensitivity caused by professionally dispensed bleaching products, as patients using it are significantly more satisfied with their whitening experience and more willing to repeat the bleaching treatment.18
Frequently associated with whitening, dentin hypersensitivity is based on the hydrodynamic theory that stimuli create a pressure change in the fluid that fills dentinal tubules and is transmitted to A-delta nerve fibers in the dentinal tubules.1 The nerve fibers transmit the stab of pain commonly associated with sensitivity. Cold contracts the fluid in the tubule, while heat expands the same fluid, changing the pressure levels inside dentinal tubules. Exposed dentinal tubules resulting from gingival recession or enamel loss are the cause of dentin hypersensitivity.1
While whitening may lead to sensitivity and caffeine may damage and discolor tooth surfaces, modern lifestyles leave little time for practicing optimum oral health, making dental professionals’ roles imperative. Dental professionals should be aware—and concerned—about patients’ stress levels and lifestyles and how they are affecting their teeth. By focusing on your patients’ attitudes towards beauty and their employed beauty habits, you may be able to identify symptoms and causes of tooth wear that will help diagnose and prevent future erosion. If left untreated, tooth wear will continue until lifestyle changes are made. Dental professionals cannot force a patient to change his or her lifestyle, but they can prescribe tools and treatments that reduce tooth wear and treat the symptoms that result from worn-out teeth.
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15. American Academy of Cosmetic Dentistry. Teeth Whitening Makes Smiles Sparkle After Quitting Smoking. American Academy of Cosmetic Dentistry Web site. Available at: www.aacd.com/media/releases/pr2002_11_18.aspx. Accessed June 28, 2007.
16. American Academy of Cosmetic Dentistry. Cosmetic Dentistry Booms as Beautiful Smiles Make Summer Sizzle. American Academy of Cosmetic Dentistry Web site. Available at: www.aacd.com/press/releases/2005_06_16.asp. Accessed June 28, 2007.
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18. Haywood VB, Cordero R, Wright K, et al. Brushing with potassium nitrate dentifrice to reduce bleaching sensitivity. J Clin Dent. 2005;16(1):17-22.
About the Author
Robert Margeas, DDS
University of Iowa College of Dentistry
Department of Operative Dentistry
Iowa City, Iowa
Des Moines, Iowa