Enamel erosion: why teeth are disappearing without decay and without grinding

Enamel erosion: what to know before your check-up

• Enamel erosion produces signs before there is any pain: transparent incisal edges, a dull surface, fillings standing proud of the tooth.
• The advice to wait half an hour after something acidic before brushing is not strongly supported by research. Absence of evidence of harm is not, however, evidence of benefit.
• The classic sign, cup-shaped hollows on the cusps, is now being questioned as a criterion for diagnosing erosion.
• Acid arrives from two directions: from food and drink, or from the stomach; the second route matters more than it seems.
• Lost enamel cannot be rebuilt; only the shape comes back, and it comes back in a material.
• Reflux and vomiting call for investigation outside the dental practice. Protecting the teeth alone does not remove the cause.
• The mechanism: acid dissolves the tooth, bacteria play no part, so this is not decay; the toothbrush is not the cause, though it can be an accomplice.

Patients explain transparent incisal edges to themselves in two ways: that the enamel has worn out with age, or that they brush too hard. Neither accounts for the whole picture. A tooth through which, held up to the light, the inside of the mouth shows through has often lost its enamel chemically - and enamel erosion runs without decay, for a long time without pain, and without any trace the patient would know how to connect to a cause.

What does enamel erosion look like on a tooth?

Not like decay: enamel erosion makes no hole, it smooths and flattens, and it is recognised by shape.

Enamel erosion gives several signals that a clinician assesses during a check-up:

• the incisal edges of the front teeth become transparent, and later uneven and brittle;
• the tooth surface loses its shine and looks matt;
• fillings begin to stand proud of the tooth surface, because the enamel around them is being lost;
• the cusps of the molars lose their sharp outline and become rounded;
• shallow cup-shaped hollows appear on the tips of the cusps.

Textbooks describe cupping on the cusps as a typical sign of erosion, as distinct from flat facets, which are attributed to mechanical wear. A three-year observation from a German centre challenges that division: in previously untouched sites, a facet forms first and the cup develops out of it. The same mandibular first molar was scanned every year in 74 dental students and the scans were compared by computer. The authors conclude from this that a cup on the tip of a cusp may not be a reliable criterion for diagnosing erosion. If the cup is a late stage of the same process, a diagnosis cannot rest on a single shape. It rests on the history and on the distribution of changes across the whole arch, and for the patient that means enamel erosion cannot be diagnosed from a phone photograph or from one cusp looked at.

Some of the signals can be checked at home, before the appointment.

The upper front teeth are examined against the light: the question is whether the incisal edge has become glassy and whether the darker background of the mouth shows through it. What a patient will usually not see in themselves is the inner surfaces of the upper teeth, which is where stomach acid lands. That area is assessed only by a clinician during a check-up.

Erosion, attrition or abrasion: how do they differ?

The same signs can have three different mechanisms, and each calls for something different.

Enamel erosion is the dissolving of tissue by acid. Attrition is tooth wearing against tooth, typical of bruxism. Abrasion is wear by a third body: a toothbrush, a toothpaste, hard food.

The literature rarely describes them separately, because in the mouth they rarely act separately. Worn enamel is usually the result of more than one of these mechanisms at once, hence the collective term: erosive tooth wear. Acid lowers the hardness of the surface, and whatever comes after it is then wearing away softened tissue. Brushing healthy enamel on its own damages it to a negligible degree; it is different with enamel that has just been in contact with acid.

That term will keep coming back below. The studies the numbers in this text come from measure wear collectively, because in the mouth the mechanisms travel together, and there are few numbers describing erosion on its own, separated from grinding.

Cervical lesions, the wedge-shaped notches right at the gumline, are a separate matter again. Erosion can be one of their causes, but not the only one: toothbrush pressure and occlusal overload are also held responsible, though the contribution of the latter is disputed. The shape of the notch therefore says nothing about the cause, nor about whether it needs filling; what decides is the depth, the response to cold and the rate at which it grows between check-ups.

With attrition the work goes into the signs of bruxism and into protecting the occlusion, with erosion into the source of the acid, and everything done to the teeth is secondary to that.

Acidic drinks and teeth: which ones really do harm?

Not so much the most acidic ones as the ones you reach for often. The size of a single serving counts for less than the number of contacts.

Erosive tooth wear is associated with acidic food most strongly of the dietary habits that have been counted: the odds of it occurring were there about 2.4 times higher than in people less exposed. Carbonated drinks raised those odds by about 40%, and dietary supplements by about 70%. The review covered 71 observational, cross-sectional studies, so they show co-occurrence and say nothing about cause. The values describe odds, moreover, and do not say how many times more often something happens.

Wear reaching the dentine was found in 6 out of 10 people (61.6%) in a Brazilian birth cohort in which 537 participants were examined clinically at the age of 31. Acidic drinks and alcohol were associated with it, though weakly. The index used there records only the fact that dentine is exposed and says nothing about the size of the lesion. That number therefore does not mean that six people in ten need treatment, only that at this age exposed dentine is common, and that the difference lies in the rate.

Habit or situation	What it does with acid	What can be changed
Lemon water in the morning, on an empty stomach	Acid reaches the teeth before breakfast, when saliva flow is low	Drink through a straw, then rinse the mouth with water
Fizzy drinks sipped over an hour	One serving is spread across a dozen or more contacts with acid	Drink with a meal, not between meals
Effervescent tablets with vitamin C or magnesium	High acidity, taken daily and over a long period	Ask your doctor about a non-effervescent form
Citrus fruit and fermented foods as a snack	Frequency of contact matters more than portion size	Eat as part of a meal, not separately
Wine tasted professionally	Acid deliberately held in the mouth, repeatedly	Rinse with water between samples, take breaks
Isotonic drinks during training	Repeated sips with a dried-out mouth	Alternate with water, do not hold in the mouth

Beyond acid, diet acts on teeth in other ways too: diet and dental health in the light of the research.

Can erosion be a symptom of reflux?

It can. Enamel erosion sometimes appears as the first visible sign of reflux, because stomach acid is considerably stronger than acid from food and reaches the teeth regularly, without the patient knowing, often at night.

Erosive tooth wear was found in 54% of people with diagnosed reflux disease, and that figure comes from a review of studies on risk groups. A separate meta-analysis of risk factors reports that regurgitation of stomach contents raises the odds of erosive tooth wear by about 130%, and that for indigestion, meaning persistent complaints from the stomach and intestines, the figure is about 80%.

An overview of reviews on reflux rates the level of evidence as low. These are observational studies, so the association must not be called causal.

The pattern of change here tends to differ from that seen with dietary acids, because stomach acid reaches primarily the inner surfaces of the upper teeth. In everyday clinical practice at Modern Dental & Orthodontics (Klinika MDO), we encounter patients for whom the first person to notice this pattern is the dentist.

It is different in people with eating disorders: in the same review, erosive tooth wear was found in 2 out of 3 such people (65%). The role of the dental practice ends at protecting the teeth and at a calm referral to an eating disorder treatment service, because treating the teeth alone changes nothing about the cause. Straight away, before any appointment, this much is in your hands: after vomiting, do not brush your teeth - rinse your mouth with water. The enamel is softened by acid at that point.

Saliva is easy to overlook, and it is saliva that dilutes acid. In people with tooth wear, the pH of stimulated saliva was slightly lower than in the rest. The difference was, however, very small, and the authors rated the certainty of the conclusion as low. Everything that limits saliva flow works against the teeth: medication, mouth breathing, dehydration - working the other way are sugar-free gum after an acidic meal and sipping water.

Does endurance sport destroy teeth?

Endurance sport by itself does not destroy teeth - the harm comes from three circumstances coinciding, and the drink is only one of them.

During prolonged exertion you breathe through the mouth, which dries the mucosa and weakens the protective action of saliva, and the dehydration that comes with it lowers saliva flow further. An isotonic drink or an energy gel therefore reaches the teeth at the moment when the natural defence is at its weakest, and it reaches them repeatedly over two or three hours.

Erosive tooth wear was found in 51% of people in a group covering occupational exposure and sport, in the same review of risk groups. That group mixes sport with occupational exposure, however, so it does not tell a runner what their own risk is.

In the practice, enamel erosion usually looks like this: a runner in their thirties, without a single carious lesion, with transparent incisal edges and a conviction that they brush too hard.

This does not mean isotonic drinks have to be given up. The point is to break the series of contacts with acid.

Three levels of advancement: monitoring, protection, restoration

Enamel erosion has no single threshold for treatment.

Level one, monitoring. Changes visible in the enamel only, with no exposed dentine and no symptoms. Management: establishing the source of the acid, changing habits, fluoride toothpaste, a review in six months. Nothing more is needed, and drilling at this stage takes away healthy tissue. One question stays open here: the advice to wait half an hour before brushing is not strongly supported by research, and the authors of the review state plainly that solid clinical studies are lacking. The recommendation to "find the source of the acid" itself stands on mechanism and on clinical practice, because there are no randomised studies that have tested it. The study that measured tissue loss prospectively found no association with reported exposure to acids, but it covered 74 dental students, one tooth, and a group from which people with bulimia were excluded.

Level two, protection. Dentine exposed, the tooth reacting to cold, fillings beginning to stand proud. Management: everything above plus in-practice preparations and careful monitoring of the rate of change.

Toothpastes with fluoride and chitosan reduced tissue loss compared with placebo in a study run on an appliance worn in the mouth, on samples of bovine enamel and dentine. Brushing increased tissue loss there on already eroded enamel, but not on dentine. This is an experimental model. There were no patients in it. A response to cold has its own causes and its own management; these are covered in the article on tooth sensitivity.

Level three, restoration. Loss of crown height, difficulty with appearance or with function. This is where restoration of worn and eroded teeth with a filling, an inlay or a veneer comes in, and where wear covers the whole arch, full occlusal reconstruction.

Laboratory-made composite onlays failed on molars more often than direct restorations in a randomised study in 41 patients with severe tooth wear; with palatal veneers there was no difference.

The rate of tissue loss varies a great deal between individuals, and in the three-year observation mentioned above the rate in one year did not predict the rate in the next. A single check-up is therefore not enough to judge whether the process is fast.

How to break the series of contacts with acid

Start with something that needs no dental practice: for a week, write down with times what goes into your mouth between meals.

If there is nothing acidic on that list, the source of the acid has to be looked for on the stomach side.

The rest is four changes, all of them to be introduced straight away. Move acidic food and drink into meals instead of spreading them across the whole day. Do not sip acidic drinks over an hour and do not hold them in the mouth. After acidic food and drink, rinse your mouth with water, and brush your teeth with a soft brush, without pressure. Effervescent tablets taken daily should be reported to your doctor, with a question about a non-effervescent form.

What these changes will not do: they will not rebuild enamel that is already gone, and they will not replace investigation if the acid is coming from the stomach.

An acid taste in the mouth on waking, hoarseness in the early morning and heartburn more often than once a week are reason to make an appointment with a gastroenterologist, regardless of what is happening with the teeth.

Frequently asked questions

Can enamel erosion be reversed?

No. Enamel contains no living cells and does not grow back, so a lost layer will not return. What is reversible is the loss of minerals from the surface alone, before any tissue loss has formed. Once the shape of the tooth has changed, the process can be halted and the shape recreated in a material. The tissue will not grow back.

Is brushing straight after an acidic meal harmful?

There is no clear evidence that it is. In 10 of 16 studies on erosion, brushing with fluoride toothpaste straight after something acidic did not increase tissue loss, but these were mainly studies on appliances worn in the mouth, not on patients. Absence of evidence of harm is not evidence of benefit. After an acidic meal, it is safe to rinse the mouth with water and to brush with a soft brush, without pressure. After vomiting, rinsing alone is all that remains.

What should be done with the teeth after vomiting?

Rinse the mouth with water and stop there. After vomiting, rinsing alone is all that remains, because the enamel is softened by acid at that point, and brushing is then wearing away softened tissue. If the vomiting recurs, protecting the teeth alone does not remove the cause and investigation outside the dental practice is needed.

Which drinks are the most erosive?

Among the most acidic are carbonated drinks, citrus juices, energy and isotonic drinks, and effervescent preparations. What decides the strength of the effect, however, is not the sour taste itself but the amount of acid in the drink and how long it stays in the mouth. Frequency of contact weighs more than the size of a single serving.

Is fluoride toothpaste enough for erosion?

Not on its own. An anti-erosive fluoride toothpaste reduced tissue loss in a study on an appliance worn in the mouth, but it acts on the effect. It does not touch the cause. If the source of the acid remains, the tissue loss progresses more slowly and that is all. Establishing that source, dietary or gastric, is the condition for halting the process and the first thing a clinician looks for.

Does enamel erosion hurt?

For a long time it does not. Pain appears only once the layer of enamel has gone and the dentine is exposed, and it then usually takes the form of a brief sting from cold or from something sour. Absence of pain is therefore not proof that nothing is happening, which is why erosion is most often picked up at a check-up.

Will whitening help when teeth have darkened from erosion?

Whitening acts on deposits and on discolouration within the tissue, whereas with erosion the darker colour comes from something else: the enamel is thinner and the dentine shows through it. The procedure will therefore not remove the cause of the discolouration. The order is decided by the state of the enamel assessed before the procedure, because on teeth with exposed dentine whitening increases sensitivity.

How can you tell the process has stopped?

You cannot see it in the mirror. Enamel erosion progresses slowly enough that the naked eye cannot compare the state of a few months ago. That will be shown only by comparison with a photograph or a scan taken earlier, and the first sensible point for such a comparison is around six months after a baseline has been established.

When is a prosthetic restoration needed?

When the loss of tissue has changed the height of the crowns or prevents biting properly, and also when it is a problem for appearance - worn enamel on its own, without those consequences, is not yet an indication for restoration. Where the changes are confined to the enamel, the appropriate management remains monitoring and removal of the cause.

Can a dentist diagnose reflux?

Diagnose it, no. Suspect it, yes. The characteristic distribution of tissue loss on the inner surfaces of the upper teeth is a signal that justifies referral to a gastroenterologist. Reflux disease is diagnosed by a physician on the basis of investigations, and treating the teeth alone does not remove its cause and does not halt further tissue loss.

How is your dentist to know it's acid?

Your dentist will usually not ask how often something acidic goes into your mouth during the day, so say it yourself. They will usually not ask either whether you wake with an acid taste in your mouth or with hoarseness. And they will not ask about medicines or about the effervescent supplements you take. It is worth asking, while you are there, for a baseline - a photograph or a scan against which the state in six months can be compared.

A warning that is easy to miss: absence of pain means nothing here.

Enamel erosion runs without symptoms for years, and the moment it starts to hurt is usually the moment when the dentine is already exposed.

Read more:

• Aesthetic and Restorative Dentistry in Warsaw
• Tooth sensitivity - why cold hurts and what actually helps
• Worn Teeth (Bruxism) — When Is Full Occlusal Reconstruction Needed?
• Bruxism - symptoms: eight signs your dentist spots before you do
• Diet and Dental Health — What Science Says About Xylitol, Green Tea and Cheese

Content and liability disclaimer

This article is informational and educational in nature and does not constitute medical advice, a diagnosis or a therapeutic recommendation — it does not replace a consultation with a specialist. If you are experiencing symptoms, have doubts or are facing a decision about treatment, consult a dentist. The methods described and the data cited are general in nature. The results of scientific studies relate to populations, not to an individual patient. The course and outcome of therapy depend on the individual clinical situation and may vary between patients. No information contained in this article constitutes a guarantee of result. The content has been prepared with due care, based on publicly available medical knowledge and the scientific publications indicated in the Sources section. We do not advise taking or refraining from any health-related action solely on the basis of the content of this article, without prior consultation with a doctor.

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