Tag: dental erosion

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 that includes the pH of their drinks).

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 demineralisation happens when the pH in the mouth drops below 5,5. This is a fact. And when knowing this, it is difficult to accept that the sparkling water is not harmful if the pH is as low as 4.

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 otherwise acidic drink (sport drinks) is even worse situation. Still water (tap) would be the best option.

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 in the beginning of the post) 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 mode 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 or not.

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.

My experience in the clinical field has proven that it is not all that simple when it comes to erosion and hypersensitivity. What us dental professionals should keep in mind is the whole picture of patients’ oral health. There’s no harm telling patients that it is worth trying to avoid sparkling water for few months to see if it makes a difference to the sensitivity. But remember also give advice on oral hygiene and eating habits.

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Eeny Meeny Miny Moe – Which Type of Tooth Wear?

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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.

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. If there are also receding gums on the same teeth as where the tooth wear is, the dentist makes a wrong conclusion easily. 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. She’s afraid that the bleeding means her gums are receding.

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

4. Check if the gums have receded on affected sites.

If you get positive answer to even one question the chances are great for the tooth wear to be an abfraction. 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 that these fillings in the cervical area can be 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 memorise 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 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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