No one goes through life without at least one dental problem, and most likely, it is due to cavities or tooth decay.
All sorts of bacteria, viruses and fungi make up the normal flora of your mouth, and they are generally harmless in small quantities.
A diet high in sugar creates conditions in which acid-producing bacteria can flourish.
This acid dissolves tooth enamel and causes dental cavities.
However, sugar isn’t the only culprit when it comes to tooth decay.
High levels of acid in your food and drinks can be just as harmful.
Any foods containing citrus, carbonated beverages, fruit juices, wine or alcohol, along with acid coming up from your stomach, can wear away your teeth, causing decay, sensitivity and discolouring.
These acids can soften the tooth surface, making it easier for it to be worn away by abrasion or tooth grinding.
The result: tooth surface loss or dental erosion.
Explains Universiti Malaya Dentistry Faculty consultant prosthodontist Associate Professor Dr Prema Sukumaran: “It’s a chemical process that involves acid, but not acid that is produced by bacteria, which makes it different from caries or cavities.
“This acid can come from an intrinsic source (stomach) or extrinsic sources (diet).
“Most patients don’t notice anything initially as teeth demineralisation is a slow process.
“Dental erosion only becomes apparent when it alters a patient’s appearance and impairs their function; that’s when they seek treatment,
“You can have a mouth that is eroded, but is caries-free, or the other way around. Or you can get them together.”
Loss of tooth surface can be a result of erosion, attrition, abrasion and a small component of abfraction (loss of tooth structure where the tooth and gum come together).
Says Assoc Prof Prema, “Erosion is a chemical process, while attrition is the physical wearing-off of the tooth surface when tooth and tooth come into contact, i.e two hard surfaces meeting, which could happen from grinding at night.
“Abrasion is when some other component comes in contact with the tooth, e.g. a toothbrush’s hard bristles or abrasive toothpaste. In the long term, we can see abrasive lesions.”
One of the signs of dental erosion is a smooth, glazed appearance of the teeth.
Dental erosion can make any exposed tooth root sensitive to hot, cold or sweet foods and drinks.
A tooth is composed of three layers: enamel (the visible, outermost layer), dentine (the second or middle layer, which is yellowish in colour) and pulp (the centre and softest layer of the three, containing vital tissues composed of blood and nerves).
When there is advanced dental erosion, the enamel may wear away to reveal the underlying dentine; these areas look like yellow depressions on the tooth surface.
Other signs include teeth appearing shorter, amalgam (liquid mercury and metal alloy mixture) fillings becoming more prominent as the surrounding tooth surface dissolves due to erosion, and chewing surfaces of the tooth becoming flatter and smoother.
“The teeth can be so badly eroded that only the dentine is visible, and because this layer is soft, it erodes faster, ” says Assoc Prof Prema.
“Once the dentine erodes and the pulp is left, the sensitivity increases and you can get pain.
“Some patients ask for the tooth to be extracted when the nerves get infected and they cannot withstand the pain.
“Or the tooth structure is so short that when you eat something hard, it fractures.”
How quickly the teeth erodes depends on many factors.
For some patients, it’s snacking on one too many acidic edibles like jeruk and asam, or drinking carbonated beverages or fruit juices such as lime, orange, grapefruit, apple, lemon or cranberry.
Says Assoc Prof Prema, “When these snacks are eaten in large quantities very frequently, the rate of erosion is faster as opposed to a person who drinks five to six cans of carbonated drinks daily.
“It also depends on how the drink goes in.
“Some people use a straw and the drink goes straight to the throat, while others have a habit of swishing the liquid between the teeth to increase the bubbles and decarbonise the drink.
“When you retain the drink longer in the mouth, these carbonated and acidic beverages are in contact with the teeth for a longer period, hence it increases the wear rate.
“Wine drinkers are at higher risk, especially those who like sparkling wine.
“For wine tasters, it is an occupational hazard and it’s not surprising that we find them with heavily eroded teeth.
“So take everything in moderation and change the way you drink acidic beverages.”
Many people are unaware that certain fruits have a high level of titratable acidity, a measurement of the total acid concentration in a food.
In citrus fruits, it is an important parameter in determining fruit maturity and sour taste.
She says: “Nobody looks at this. Fruit juices are healthy, but have a higher titratable acid number, so you need a lot more saliva or alkaline to buffer the acid in your mouth.
“You have to balance it out with things like milk or cheese.
“Swishing your mouth with water can help as water is not abrasive.”
Saliva, the saviour
She advises against drinking acidic beverages at night, when salivary function is reduced and not able to buffer the acid in the mouth.
Saliva is a powerful natural defence against erosion as it can neutralise acids and wash them out of your mouth into the stomach, as well as repair tooth minerals during the early stages of tooth softening.
However, it cannot restore the lost tooth surface.
A reduced flow of saliva (dry mouth) can also increase your risk of dental erosion.
Staying well-hydrated improves saliva production.
“Remember that as the day goes by, saliva increases, then it decreases at night.
“Some patients have reduced salivary functions because they are taking certain medications.
“Athletes who undergo intense physical training can become dehydrated and have less chance of saliva buffering when they take sports or isotonic drinks, ” says Assoc Prof Prema.
Another no-no is to brush the teeth immediately after drinking or eating acidic stuff.
She says, “Once the acid enters the mouth, there is a vulnerable period when the tooth surface is softer and the oral environment is compromised.
“When you brush your teeth over it, you’re exerting force, which can wear off the teeth over a long period of time.
“So wait at least 30 minutes (after eating or drinking) before brushing your teeth.”
Generally, anything with a pH value of 5.5 or lower is capable of softening the surface of enamel in only a few minutes.
From the inside
Intrinsically, our own acid from our stomach is also a major contributor towards dental erosion.
Says Assoc Prof Prema, “The patient may have gastroesophageal reflux disease (GERD, or acid reflux) and it could be a ‘silent’ condition.
“The acid that travels out of the stomach has a pH of around two and that is very acidic. It affects the upper surfaces of the teeth.
“Some patients who have eating disorders can also present with dental erosion, along with another group who ruminate (they swallow the food and intentionally regurgitate, then swallow it back), though this is not very common in Malaysia.
“So medical and dental practitioners have to be able to identify whether the erosion is intrinsic or extrinsic.”
Individuals of all ages can present with the condition.
While there is no nationwide study on dental erosion among the Malaysian population (our national Oral Health Survey only covers caries and gum disease), there was one 2017 study involving 16-year-olds in Kuantan, where 45% of the 598 participants were found to have dental erosion of moderate severity.
She says, “There was another study in the United Kingdom that showed significant erosion among three- to seven-year-olds.
“Sometimes, toddlers and infants consume sweet fruit juices using a feeder bottle for comfort.
“When the child holds that bottle and falls asleep, the acid pools in the mouth and can cause erosion.”
She adds, “There is a worldwide trend of children drinking carbonated drinks, and when they grow up, they still drink these instead of coffee or tea.
“Educating the public on carbonated drinks and the manner in which it is consumed is our biggest challenge.”
Striking a balance
A healthy diet also has its repercussions, especially when citrus foods and juices are being consumed in large amounts.
Assoc Prof Prema suggests, “Instead of having an orange a day, alternate it with a banana or papaya.
“Having an orange a day is like causing a landslide – when it rains, it hits the cliff every day and the erosion is faster.
“Some people also like to suck on oranges or unripened mangoes.
“Again, the longer the acidic substance comes into contact with the teeth, the higher the chance of erosion.
“I’m not saying don’t eat healthy stuff, but do pay attention to the acidic foods you’re eating.
“If you feel it is in excess, then reduce it a bit.”
There are many methods to treat dental erosion, depending on the severity of the problem.
If the erosion is localised to the anterior (front) teeth, the Dahl concept is used to create space by separating the posterior (back) teeth using an anterior bite plane.
Dental erosion greatly affects a person’s smile and self-esteem.
“Erosion only affects the natural teeth, not plastic teeth, dentures or crowns.
“What is lost is lost and cannot be recovered.
“Our main objective is to stop the erosion and make sure it doesn’t progress, ” she says.
“If the tooth is not salvageable and cannot be restored, or it is fractured unfavourably, then it’s best to extract it.
“The aim of the game is to preserve what we have in the mouth rather than replace everything that is missing.
“So, see a dentist every six months to identify the problem soon, ” she advises.
Some tips from Assoc Prof Prema to prevent dental erosion:
- Reduce the quantity and frequency of acidic foods and beverages.
- Avoid consumption at night.
- Don’t hold acidic drinks in your mouth. Gulp or place a straw at the back of the throat so the liquid doesn’t come in contact with the teeth.
- If your meal is highly acidic, end it with an alkaline substance such as milk.
- Sip water alongside or after the acidic food or drink to wash it out of your mouth.
- Wait at least half an hour before brushing your teeth after a meal.
- Use a fluoridated mouth rinse to increase abrasive resistance and stop using toothpaste without fluoride.
- Visit the dentist to get a topical fluoride application. When fluoride is present in the mouth at sufficient levels, its release helps stop the dissolution of calcium and phosphate in enamel, thus strengthening tooth structure.