Abrasion loss of tooth structure by contact between tooth and another source, usually without any evidence of decay or decalcification. (i.e. toothbrush abrasion).

• Sour candies are very acidic, with a low pH.
• Acid weakens and wears away tooth enamel.

• Sensitivity may occur when tooth enamel wears away.
• The discoloration is visible as a slightly yellow appearance on the tooth crown or root surface.
• The translucency of the front teeth may appear along the biting edges.
• Rounding of teeth occurs along the surfaces and edges of the teeth.
• Cracks and roughness appear along the edges of the teeth.
• Cupping (which appears like potholes in the tooth) develops on the chewing surfaces of the teeth. At this severe stage, fillings may actually appear to stand proud.

• Reduce or eliminate consumption of sour candies.
• If you do eat sour candy, swish your mouth with water, drink milk, or eat cheese afterward to neutralize the acids.
• Chew sugar-free gum to produce saliva which protects tooth enamel. We recommend Sugar-free gum with Xylitol (I.e. Hershey’s Ice Breakers).
• After eating sour candy or other acidic foods or drinks, wait one hour before brushing your teeth. Brushing right away increases the harmful effects of acid on teeth.
• Ask us about ways to reduce sensitivity or minimize enamel loss if erosion has begun.

Every attempt should be made to reduce the frequency of consumption of acidic candies, and such foods should be restricted to main meals. For example, a change in the timing of eating sour candy between meals or at bedtime to mealtime can reduce the severity of the acid attack due to more efficient clearance time and the buffering benefits of saliva. Patients are encouraged to finish a meal with something neutral or alkaline — cheese, milk, or sugar-free chewable antacid tablets. Chewing sugar-free gum will stimulate saliva flow, providing a natural buffering action. Rubbing bicarbonate containing toothpaste on the teeth with a fingertip will reduce the acid challenge on the tooth surface. Also, rinsing with water rather than brushing teeth immediately following an acid challenge can reduce demineralization by clearing the acid from the oral cavity, and will prevent inordinate damage by toothbrush abrasion of the fragile enamel surface. Finally, patients should use less abrasive “sensitive” toothpaste or those with bicarbonate as an active ingredient, rather than highly abrasive whitening toothpastes.

The goal of restorative treatment should be to maintain adequate function and esthetics of primary and permanent teeth. Erosion from the chewing or sucking of acidic candy primarily affects the top surfaces of the posterior teeth. Eroded primary teeth should be restored to maintain bite opening and tooth size, reduce symptomatic sensitivity, and provide nerve protection for the maintenance of vitality until the tooth is lost. Frequently, full-coverage stainless steel crowns are the most appropriate restorative choice for severely eroded posterior primary teeth.

The restoration of eroded permanent teeth requires choosing the least invasive procedure while providing maximum protection from the further loss of tooth structure. Sealants and resin-bonded restorations in “cupped” cusp tip lesions will provide mechanical protection for the affected surfaces, reduce dentin hypersensitivity, and improve the appearance of severely eroded posterior teeth. Many of these teeth will eventually require crowns to preserve the remaining tooth structure and provide adequate esthetics and function. Since full-coverage restorations are costly and involve significant additional loss of tooth structure, it is essential that appropriate early counseling and behavior modification should occur to prevent the need for such invasive treatment.

• The acid in soft drinks, whether they contain sugar or not, is the primary cause of weakening tooth enamel.
• The acid attacks your teeth. Each acid attack lasts about 20 minutes.
• The acid attack starts over again with every sip.
• Ongoing acid attacks weaken your tooth enamel.
• Bacteria in your mouth cause cavities when tooth enamel is damaged.
• If you have a receding gum line, acid does more damage below the gum line than above it. This is particularly a concern for adults.
• Drink soft drinks in moderation.
• Use a straw to keep the sugar away from your teeth.
• After drinking, swish your mouth out with water to dilute the sugar.
• Never drink soft drinks or juice before bedtime because the liquid pools in your mouth and coats your tongue and teeth with sugar and acid.
• Drink water instead of soft drinks. It has no sugar, no acid, and no calories.
• Get regular checkups and cleanings to remove bacteria buildup (plaque). Floss, too.
• Use fluoride toothpaste to protect your teeth.

Data courtesy of Dr. John Ruby, University of Alabama Birmingham School of Dentistry, 2007. Also, most of this data can be found on the Minnesota dental association’s website.

Fluoride helps teeth resist decay by strengthening the protective layer of tooth enamel, and can reverse newly formed cavities. Fluoride has been added to U.S. drinking water supplies since 1945. More than two-thirds of the population in the U.S. are served by public water systems that are optimally fluoridated.

Starting November 19, 2007, Metropolitan Water District (MWD) began adding fluoride to the water that it serves to Newport Beach. In line with recommendations from the California Department of Public Health, as well as the U.S. Centers for Disease Control and Prevention, MWD will adjust the natural fluoride level in the water, which ranges from 0.1 to 0.4 parts per million, to 0.7 to 0.8 parts per million. Currently, the City of Newport Beach receives approximately 18% of its water from MWD and 82% from its groundwater well sources. The City of Newport Beach will not be adding fluoride to its well sources. The City of Newport Beach’s groundwater well sources contains a natural occurrence of fluoride Also beginning this November, the City of Newport Beach will begin a fluoride monitoring program to monitor the levels of fluoride throughout the distribution system.

Drinking optimally fluoridated water on a regular basis makes the use of fluoride tablets or drops unnecessary. However, the continued use of fluoride treatments by professional dental caregivers is recommended. Drinking fluoridated water should be part of a total treatment plan for healthy gums and teeth, combined with brushing and flossing your teeth regularly and using less sugar in your diet. People who do not wish to drink fluoridated water should know that most bottled waters do contain levels of fluoride below the optimum range.

Bisphosphonates (i.e. Fosamax, Actonel, Boniva) and their role in bone death.

If you use a bisphosphonate medication for osteoporosis or as part of cancer treatment therapy you should advise your dentist. In fact, any time your health history or medications change, you should make sure the dental office has the most recent information in your patient file. The American Dental Association recommends that a patient be examined by a dentist prior to initiating bisphosphonate therapy to reduce further complications.

Some bisphosphonate medications (such as Fosamax, Actonel, Boniva) are taken orally to help prevent or treat osteoporosis and Paget’s disease of the bone. Others, such as Aredia, Bonefos, Didronel, or Zometa, are administered intravenously as part of cancer therapy to reduce bone pain associated with metastatic breast cancer, prostate cancer, and multiple myeloma.

In rare instances, some individuals receiving intravenous bisphosphonates for cancer treatment have developed osteonecrosis of the jaw, a rare but serious condition that involves severe loss, or destruction, of the jawbone.

Pain, swelling, or infection of the gums or jaw
Gums that are not healing
Loose teeth
Numbness or a feeling of heaviness in the jaw
Drainage
Exposed bone

The following information comes directly from the American Dental Association and can be found on their website at www.ada.org

Reports of bisphosphonate-associated osteonecrosis of the jaw (BON) associated with the use of Zometa (zoledronic acid) and Aredia (pamidronate) began to surface in 2003. The majority of reported cases have been associated with dental procedures such as tooth extraction; however, less commonly BON appears to occur spontaneously in patients taking these drugs. Zoledronic acid and pamidronate are intravenous (i.v.) bisphosphonates used to reduce bone pain, hypercalcemia, and skeletal complications in patients with multiple myeloma, breast, lung, and other cancers and Paget’s disease of bone.

Several cases of BON have also been associated with the use of the oral bisphosphonates, Fosamax (alendronate), Actonel (risedronate), and Boniva (ibandronate), for the treatment of osteoporosis; however, it is not clear if these patients had other conditions that would put them at risk for developing BON.

The table below lists all oral and i.v. bisphosphonates currently on the market in the U.S.

The typical clinical presentation of BON includes pain, soft-tissue swelling, and infection, loosening of teeth, drainage, and exposed bone. These symptoms may occur spontaneously, or more commonly, at the site of previous tooth extraction. Patients may also present with feelings of numbness, heaviness, and dysesthesias of the jaw. However, BON may remain asymptomatic for weeks or months, and may only become evident after finding an exposed bone in the jaw.

It is important to understand that, based on the information currently available, the risk for developing BON is much higher for cancer patients on i.v. bisphosphonate therapy than the risk for patients on oral bisphosphonate therapy. Therefore, there are different recommendations for the dental management of these patients.

The risk of developing BON in patients on oral bisphosphonate therapy appears to be very low; however, though the risk is small, currently millions of patients take these drugs. Therefore, recommendations for dental management of patients on oral bisphosphonate therapy were developed by an expert panel assembled by the ADA’s Council on Scientific Affairs. These panel recommendations focus on conservative surgical procedures, proper sterile technique, appropriate use of oral disinfectants and the principals of effective antibiotic therapy. There is currently no data from clinical trials evaluating dental management of patients on oral bisphosphonate therapy, and therefore, these recommendations are based on expert opinion only. A comprehensive oral evaluation is recommended for all patients about to begin therapy with oral bisphosphonates (or as soon as possible after beginning therapy).These recommendations do not address treatment of patients on i.v. bisphosphonate therapy or patients with BON. Refer to the information below regarding their treatment.

It is important for dentists to be aware that while on treatment, invasive dental procedures should be avoided in patients receiving i.v. bisphosphonates, if possible. Dentists need to exercise their professional judgment, perhaps after consultation with the patient’s physician, in deciding whether invasive treatment is needed under particular clinical situations.

The prescribing information for these drugs recommends that cancer patients:

Receive a dental examination prior to initiating therapy with intravenous bisphosphonates (Aredia and Zometa), and avoid invasive dental procedures while receiving bisphosphonate treatment. For patients who develop osteonecrosis of the jaw while on bisphosphonate therapy, dental surgery may exacerbate the condition. Clinical judgment by the treating physician should guide the management plan of each patient based on an individual benefit/risk assessment.

Among tools useful to the dentist is a patient’s medical history, including medications. Dentists should be aware that patients may not relay information about receiving i.v. bisphosphonates, because these drugs are administered in oncology wards. Therefore, patients with a history of multiple myeloma, metastatic cancer, Paget’s disease, and osteoporosis may need to be questioned about receiving i.v. bisphosphonates. In addition, it may be important to know of any history of i.v. bisphosphonate administration, because these drugs have a long half-life (years).

An expert panel convened by Novartis Pharmaceuticals Corporation (the manufacturer of Zometa and Aredia) in 2004, made the following recommendations for prevention, diagnosis, and treatment of osteonecrosis of the jaw in patients on i.v. bisphosphonate therapy:

Patients should be educated on maintaining excellent oral hygiene to reduce the risk of infection.
Dentists should check and adjust removable dentures to avoid soft-tissue injury.
Routine dental cleanings should be performed with care not to inflict any soft-tissue injury.
Dental infections should be managed aggressively and nonsurgically (when possible).
Endodontic therapy is preferable to extractions; and, when necessary, coronal amputation with root canal therapy on retained roots to avoid the need for extraction.

Recommendations for the treatment of patients with BON have been published and are posted on the Web site for the Journal of Oncology Practice.