Dental Erosion and Tea

Seven_Sisters_Panorama,_East_Sussex,_England_-_May_2009.jpg

By Diliff – Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=6739706

As a dental professional I worry about growing phenomenon of dental erosion on patients teeth. Yesterday I saw 6 patients of which 5 of them had erosion on their teeth ranging from mild to very severe. There is not necessarily difference between different age groups any more. Dental erosion affects all the age groups and often it is due to ignorance – not knowing that something we do everyday basis is damaging our teeth. And damaging for good. With this post I hope to raise awareness of one very common habit many of us have that could damage the enamel of the tooth. That is drinking tea.

What is Erosion?

People often know what erosion means when it comes to for example coastal erosion (hence the photo of beautiful Seven Sisters, UK). But when I mention the word erosion to the patient, they often look perplexed.

Dental erosion is one type of tooth wear where tooth looses its structure due to chemical dissolution by acids. These erosive acids enter the mouth through two routes – from outside (food, drinks, medicine, supplements) or from inside of the individual (stomach acid due to gastric reflux or bulimia). The loss of the tooth structure is permanent. It won’t grow back. So the prevention of the dental erosion is the most important thing to do.

With this post I will not go into all the things that cause dental erosion as I have written it in my previous post How Diet Affects Your Teeth? But what I didn’t write on that post was something I didn’t know back then. You see, this profession is constant learning as long as you are receptive. I knew that fruit teas are acidic but what I did not know is that only two types of teas are safe to drink when it comes to tooth wear.

pH of Different Teas

There are plenty of studies about the pH levels of different teas. Just google words erosive potential of teas. When I did this I also run into some worrying sites like this one where incomplete advice is given to people. The effects on teeth is completely left out when talking about alkaline diet even though the mouth is one important part of your overall health.

What people following alkaline diet are thinking is that foods consumed will become alkaline in your body. But remember when acidic foods (lemon, lime, berries, apples etc) or drinks (e.g. herbal and fruity teas, carbonated drinks, juices) enter the mouth, they stay acidic. Lets take the lemon as an example. In the alkaline diet’s pH chart they state that lemon is very alkaline (pH 10). But when entering mouth, it is highly acidic (pH 2.0)

The same site advises people to drink hibiscus tea as alkaline tea. A revelation, also hibiscus is not alkaline when entering mouth. It is in fact the most acidic tea there can be (pH level <3.0). Any drink with pH level below 5,5 will cause erosion on enamel if consumed regularly.

It worries me that people actually follow these constricted advices blindly. I don’t blame them. Many people are clueless when it comes to matters of health. Everyone following alkaline diet should read this article to determine if there are enough health benefits of the alkaline diet to risk the health of the teeth. The only downfall of this article is that it is not writing about health risks of alkaline diet.

Erosion-Enhancers

The herbal and fruity teas are acidic but certain factors can make them even more erosive. These are exposure time and temperature of the drink.

Nowadays people carry their drinks with them in a travel mugs enabling them to sip it during e.g. commuting and perhaps some of it is left for them to drink when they reach their desk. If the drink is acidic tea it means prolonged exposure to acids and if repeated often, it will result in tooth erosion. If there is sugar or honey added to the drink it will be even more erosive and also cariogenic.

Also the hotter the drink is the more erosive it is. And these travel mugs keep the drink warm for a long period of time.

Warning Signs of Erosion

The first sign of dental erosion is normally sensitivity to cold or pressure (when brushing the teeth or touching the surface of the tooth with your finger nail. The latter us professional do not encourage to do). This should raise an alarm in your mind and you should go through your diet to find out if you are consuming something regularly that is too acidic to your teeth. You will find help from my post How Diet Affects Your Teeth. Remember that the best drink teeth-wise between the meals is tap water because it is alkaline.

Another sign of tooth wear is change in tooth colour. As the enamel gets permanently thinner, the yellower tooth structure the dentin under the enamel will start to show through. Your teeth will look yellower than before and no whitening done will change that as the whitening substance is not able to reach the dentin.

When the shape of your tooth is changing, the erosion is already severe. Thinning enamel will easily chip off making your teeth look less attractive than they used to be. Often people feel embarrassed about their teeth at this point.

So my message to you all is to prevent dental erosion! Think what you put in your mouth and how often you do that. Occasional acidic drink will not make any difference but when consumed often, it will cause problems.

Is Any Tea Safe to Drink?

Yes! The pH level of green tea and black tea are on the safe side. Black tea also contains fluoride which helps to prevent tooth erosion. But remember, they are only safe if no sugar (including honey) or lemon is added. Sugar will cause the pH level of the saliva to drop below 5,5 and lemon is very acidic like I mentioned already above.

Here are some studies for further reading

Erosive potential of herbal teas

International Journal of Science and Research (IJSR): Dental Erosion and Tea: A Systematic Review

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Eeny Meeny Miny Moe – Which Type of Tooth Wear?

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Still or Sparkling?

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Is sparkling water harmful to the teeth?

Erosion is a growing problem in dental health and our lifestyle is much to blame. Fizzy and fruity drinks are the biggest culprit but also diets high of sugar and starches. Fashionable and seemingly healthy diets like juicing do play their part as well in dental erosion (I will tell you more about juicing later on this post).

The reason I wanted to bring this subject up is that dental professionals do agree on the fact that fizzy drinks like coke and energy drinks, juices and alcohol are harmful to our teeth. But there seems to be a division amongst us when it comes to the sparkling water.

I have read health news in my country’s largest newspaper where dental professionals state that carbon dioxide in sparkling water is not harmful to the teeth as long as it is plain sparkling water, no flavours or lemon added. In my opinion and in my experience it’s not so black and white situation.

So is sparkling water harmful to our teeth? This is something I hope to find out by bringing this subject into discussion.

What Is Erosion?

To keep it short, the erosion is permanent loss of tooth structure caused by non-bacteria originated acids. These acids come e.g. from our diet, medications or medical conditions like gastric-reflux (heart burn) or bulimia.

The first structure on teeth to take the hit from these acids is the enamel. And when the enamel gets thinner this is what will follow:

  • teeth get more prone to decaying and hypersensitivity
  • the colour of the enamel gets yellower as the bone (dentin) under the enamel is darker in colour and starts to show through the thinning enamel
  • the tips of the teeth start to chip more easily and the tips become transparent and can make the tips look darker in colour as the oral cavity does not have very good lighting and this is what is showing through the thin tip of the tooth
  • the bite will become imbalanced as the tooth structure is eroding away. This might result in jaw joint problems

None of the above you should take lightly and all of them are costly to fix.

Why Do Some People Get Erosion on Teeth and Some Don’t?

Well, there are many variables that play a role in dental erosion. These are:

  • saliva’s buffering capacity – the ability to neutralise the acids. This is different with each person
  • the saliva flow. People with reduced saliva flow (dry mouth sufferers) are more at risk of erosion from acidic drinks. But even with healthy people the saliva flow increases and decreases over 24-hour period
  • the pH of the drink

Remember that the plain water’s pH is somewhere around 7 and it is not harmful to the teeth at any way

Sparkling Water and Demineralization pH <5,5

Sparkling water has carbon dioxide which will become carbon acid when it comes in contact with our mouths. The pH of the sparkling water varies but normally it is between 4-6 (click here to one bottled water company’s info page).

It is rare to find the information on the bottle about the pH of the water and often very cleverly they mention that the pH at the source is 7 which can be misleading.

Us professionals are familiar with the fact that demineralization happens when the pH in the mouth drops below 5,5. This a fact. And when knowing this, it is difficult to accept that the sparkling water is not harmful.

An example.

If the sparkling water has pH of 4,5 and the person keeps the bottle next to him at work and sips away every now and then (and perhaps even swishes it around in the mouth) then surely it is harmful to the teeth?

Another example.

Person is exercising at the gym and has sparkling water as a drink. She is dehydrated from the exercising and the saliva flow is poor due to this (= no saliva or very little saliva to neutralise the acids). She drinks sparkling water and swishes it around the mouth to ease the sense of dryness in the mouth. It must do a damage if this happens in weekly basis.

Please note that this same scenario with any other fizzy or fruity drink is even worse situation. Still water (tap) would be the best option.

Juicing

For those who are not familiar with this diet, it is a diet where the juices are extracted from the fruits and vegetables. It is not blending where you put everything in the blender and blend it away to a smoothie. Juicing is drinking fruits and vegetables as a juice.

From dental professional’s aspect this is very worrying diet. Let’s think about the worst kind of scenario where juicing can harm the teeth.

Person wakes up and makes a juice from various fruits for breakfast. One of the fruits is lemon. Then she drinks it and swishes (I use this word a lot in this post so people would get the idea what is harmful) the juice around the mouth to get a fresh feeling after the night. Then she goes and brushes her teeth – meticulously. What did she do that was harmful to her teeth?

  1. When we sleep the saliva flow decreases. When we wake up we have dry mouth and if you pour a very acidic drink (the pH of lemon juice is 2-2,6) in there, the damage is great. There is no saliva protecting and neutralising the acids
  2. It takes a while before the saliva starts flowing again in the morning. This normally happens when we chew our breakfast and start hydrating ourselves with drinks. Drinking juice won’t activate your saliva flow and acids can cause damage to the teeth in peace
  3. Brushing the teeth every morning after breakfast – especially after acidic juice breakfast – will erode the teeth for sure. You are brushing away the softened enamel

My Experience

Every once in a while I see a patient whose teeth are hypersensitive. I go through the patient’s diet, oral hygiene habits and medical history. Often the reason for hypersensitivity is snacking and poor oral hygiene (lack of fluoride and build up of plaque) but sometimes there is no other reason than the patient drinking sparkling water between the meals. Devices like SodaStream at home make it possible to carbonate drinks like water at home. Some people use them many times a day.

I once had a patient who had read the same article (mentioned above) in the newspaper in which dental professionals were saying it is ok to drink sparkling water. This patient had done research on the subject and was already in defensive mood about it. So there was no way for me to convince him otherwise. But then again I am merely a channel of information and it is patient’s right to choose whether to take the information on board.

It is easy to make people understand that flavoured sparkling water is very acidic due to the acidity of the flavouring. But many reject the suggestion that plain sparkling water could be damaging to the teeth as well. I don’t blame them as many of us dental professionals do the same. What I wonder is that how did these dental professionals come to this conclusion?

My experience in the clinical field has proven that it is not all that simple when it comes to erosion and it is damaging to the patient’s dental health to suggest that it is.

 

 

Eeny Meeny Miny Moe – Which Type of Tooth Wear?

Dental Revelations Blog-3877

There are four types of tooth wear that we diagnose from patients’ mouths. Erosion, abrasion (I’m sorry for a missing link – I did not agree with any of the images of abrasion), abfraction and attrition. The easiest ones from these to diagnose are the erosion and attrition. You can’t go wrong with them. But it is completely different case with abfraction and abrasion. I run into this very often with my patients.

When a dentist or a hygienist sees tooth wear on the neck of the tooth they diagnose it by default as abrasion caused by too vigorous brushing. They recommend softer toothbrush and this silly brushing technique called Bass (it is so silly that I think I am going to dedicate one post entirely to this technique).

This normally leads into a situation where patient begins to be too careful with the brushing because she doesn’t want to cause further damage to the teeth. That’s when the plaque starts to build up to the gum line, gum gets inflamed because of the plaque and the patient begins to notice bleeding when brushing. Now she’s even more careful with the brushing as in her mind bleeding means she’s doing something wrong – brushing too hard like the dentist said she is.

But what if the dentist/hygienist misdiagnosed the tooth wear? What if the correct diagnosis was the abfraction?

Tooth wear – What to Check?

When you see a tooth wear that you are tempted to diagnose as abrasion, stop for a moment before you proceed giving advice on brushing. Instead do the following:

1. Check if there is mobility on the teeth affected by tooth wear

2. Check if there are interferences on side movements and protrusion

3. Check if there are shiny facets on occluding surfaces

If you get positive answer to even one question the chances for the tooth wear to be abfraction are great. And in this case telling patient that the tooth wear is caused by her brushing can be damaging in many ways:

  1. It is hard to convince a patient that they are not actually brushing too hard and that they have not damaged their teeth by it. I have my ways of convincing the patient but life would be soooo much easier if I didn’t have to.
  2. The dentin will decay very easily (as I’m sure you know) and plaque accumulating and staying there undisturbed for longer period of time because of too careful brushing will very quickly cause decay. And we all know how these fillings in the cervical area are pain in the butt. Somehow they always seem to have overhangs or they come off when scaling. Sound familiar?
  3. The teeth where the surface of the root (dentin) has been exposed by receding gums will get sensitive if the plaque builds up.
  4. If the tooth is mobile and has already bone loss the plaque building up to the gum line and inflaming the gum can be disastrous. Please memorize that

MOBILITY + PLAQUE = RAPID BONE LOSS

The Cause for Abfraction Needs to Be Dealt With

When a tooth interferes with full closure, it will trigger deflective interferences6-8 and cause any of the 7 signs and symptoms of occlusal disease such as hypersensitivity, abfractions, mobility, excessive wear or fractures, and muscle or temporomandibular (TM) pain.

There is no consensus amongst the dental professionals over the right approach to occlusion. Is this the reason why signs of interferences on occlusion are ignored or unchecked and the tooth wear is so easily made as patient’s fault?

The quote above is from an article The Three Golden Rules of Occlusion in dentistrytoday.com and you can read a full article here.

But by Whom?

To be honest – and like I have expressed in my previous post – I would not let just anyone touch my occlusion. I would love if the dentists would refer patients to the specialist in prosthodontics and stomatognathic physiology because they have the best knowledge and skills to treat the occlusion. And that’s something every patient is entitled to.

Guilt Is a Heavy Load to Carry

I have often noticed that patient feel unnecessarily guilty over damaging their teeth. They feel guilty and desperate over the fact that the damage done by brushing is irreversible. And that they are not sure if their brushing technique is still damaging their teeth hence too careful brushing to make sure they are not.

I believe that guilt does not lead us forward in life, it does not bring anything positive into our lives. Therefore I always try to relieve my patient’s guilt whenever it is possible.

In the case of tooth wear and some dental professionals way of putting the blame on patients’ brushing technique I always have the same conversation with a patient. It goes like this.

Me: Have you been told that you brush too hard?
Patient: Yes I have.
Me: I thought you might have. You see when a patient is told this, she starts to be too careful and then the plaque starts to build up and there is actually plaque in the gum line of your teeth. (I take a mirror and show the plaque to the patient)
Patient: Eww..
Me: I personally try not to tell patients that they are brushing too hard because this leads to too careful brushing which will cause more problems like decaying and gingivitis. Instead I interview the patients about how they brush their teeth and correct it if necessary. You see the tooth wear can be caused by other things than just vigorous brushing… 

Prior to this conversation – in the beginning of the treatment – I have interviewed the patient and asked about her oral hygiene habits. Which brush she uses? How often? How often does she replace the brush head/brush? How does the brush head look like before replacing it? Spread or still like new apart from colour fading? This is why I can continue the above conversation like this.

Me: In your case I doubt it that the tooth wear is caused by your brushing but I will just in case show you the right technique. I will first just check couple of things…

And then I check the mobility, the interferences and the occluding surfaces. I feel great satisfaction when the teeth affected by tooth wear have mobility on the side movements. I am on the right path!

The patient is visibly relieved when they can stop worrying about their brushing. Well who wouldn’t be! There is enough to worry about in life even without worry over brushing.


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Dental Erosion and Tea