Professor Andrew Eder considers the interplay between dietary acid intake, toothbrushing, tooth surface loss and patients reporting tooth sensitivity, and how to address these challenges, read the article below:Dentistry-Jan-2020
Getting to the Root of Sensitivity
Read Professor Andrew Eders advice in the article below:dentaltownuk_2019JuneJuly
Professor Andrew Eder presents an overview of Tooth Wear and offers practical advice for supporting pathological effects in their tracks, read more…The-Dentist-April-2019
With dentists ideally placed to recognise eating disorders, to raise awareness of the effect on the dentition and to mark Eating Disorders Awareness Week, taking place from 25 February to 3 March 2019, Professor Andrew Eder considers the oral health challenges and offers preventive advice.
According to the UK eating disorders charity BEAT, around 1.25 million people in the UK have an eating disorder, with about 40% of those suffering with bulimia (www.beateatingdisorders.org.uk, 2018). Yet, in a Yougov survey conducted for Eating Disorders Awareness Week in 2018, more than one in three adults in the UK who took part could not name any signs or symptoms of eating disorders (www.beateatingdisorders.org.uk/edaw, 2018).
To give it its full medical name, bulimia nervosa is defined by The Oxford Dictionary of Dentistry as: ‘An eating disorder in which large amounts of food are eaten followed by self-induced vomiting.’
The definition continues: ‘The vomiting can lead to severe dental erosion. Patients are often fanatical about oral hygiene, which can lead to toothbrush abrasion and gingival recession.’
Oral signs and symptoms
Therefore, it is clearly important the dental profession is able to recognise the signs and symptoms of bulimia in their patients.
Extended periods of intentional vomiting causes acid erosion, which may result in:
- The teeth becoming rounded, smooth and shiny and losing their surface characteristics
- Incisal edges appearing translucent
- Cupping forms in the dentine
- Shallow and rounded cervical lesions
- Restorations standing proud of the surrounding tooth tissue, because they tend to be unaffected by erosion.
In addition, abrasion such as that potentially caused by overzealous toothbrushing may manifest as:
- Teeth becoming less white as some of the outer surface is lost
- Chewing surfaces wearing flat and taking on a shiny, pitted appearance
- Restorations such as crowns and bridges may stand proud of the natural teeth (as is also found with erosion).
Alongside this, attrition as a result of tooth grinding may present with:
- Front teeth becoming short, sharp or chipped
- Back teeth becoming shorter and opposing chewing surfaces wearing flat
- Failing and fractured restorations.
This brings up an interesting point that tooth wear is multi-factorial – dentists will not see the dentition affected just by erosion, abrasion or attrition alone or, indeed, any other recognised mechanism of tooth surface loss in isolation. This then requires a multi-factorial clinical response and, since we are dealing with a mental health disorder, dentists and their teams must approach the issue with great sensitivity.
Taking preventive action
Bulimia sufferers do tend to react with embarrassment and deny there is a problem when the issue is raised with them, so if there is a concern that needs to be addressed in dental practice, try to make them feel at ease beforehand.
You can do this, in part, by telling them you have time to talk things through, communicating on their level and asking questions in a non-judgmental manner aimed at encouraging the patient to identify the cause of their oral health problems. It may help if you share your examination findings with the patient and explain how their symptoms are linked.
At this stage, it is not about offering treatment but rather preventive advice. It may be helpful to:
- Issue a fluoride rinse or gel and prescribe a high-fluoride toothpaste for daily use
- Advise the patient not to brush immediately after vomiting or consuming acidic foodstuffs, and to rinse with a fluoridated mouthwash and chew sugar-free, xylitol-sweetened gum afterwards.
As for abrasion caused by a rough brushing technique, an important preventive message to share with patients is the need for gentle but effective brushing. Experience has shown that many people mistake brushing hard for brushing well. If properly explained to a bulimic patient, they might be able to alter their brushing habits, as long as they are reassured their oral health will not suffer – and, in fact, improve. It may also be appropriate for the dentist or hygienist to demonstrate the best brushing technique for the patient, and to recommend the use of a soft toothbrush and non-abrasive toothpaste.
In addition, extra protection may be provided via calcium and phosphate ions, to help restore the mineral balance, neutralise acid in the mouth and increase salivary flow.
Protecting the remaining dentition
Of course, getting a bulimic patient to take preventive action is easier said than done, given the nature of the disease. It may also, therefore, be necessary to protect the remaining dentition, for example direct application of a glass ionomer or composite to sensitive areas, an occlusal guard to protect the teeth during purging, and/or an alkali or fluoride gel placed within the fitting surface of the guard to neutralise any acid pooling.
Once any treatment has been completed, it is important that the patient attends for regular check-ups. This will allow monitoring of the rate of wear with models and photographs if the patient is agreeable and, when appropriate, further guidance and encouragement can be provided, together with any adjustments to lifestyle being made.
Much of what a bulimic patient goes through is, of course, beyond the scope of the dental professional and they may already be under the care of various agencies. Consequently, it may be sensible (with the patient’s consent) to contact their GP or other healthcare professional overseeing their care before beginning any course of treatment. This will facilitate a team approach, to help decide upon a course of action that will offer the best possible outcomes given the patient’s circumstances.
The London Tooth Wear Centre offers an evidence-based and comprehensive approach to managing tooth wear, using the latest clinical techniques and a holistic approach in a professional and friendly environment. If you have any concerns about your patient’s tooth wear, please visit www.toothwear.co.uk, email firstname.lastname@example.org or call 020 7486 7180.
www.beateatingdisorders.org.uk/media-centre/eating-disorder-statistics (2018) accessed 21 December 2018
www.beateatingdisorders.org.uk/edaw (2018) accessed 21 December 2018
As placed on www.dentistry.co.uk
Summer is here at last and despite the idiosyncrasies of British weather (or perhaps because of it) there will be hot days where the clink of ice in a glass, as well as the odd ice lolly or ice cream will offer blessed relief from the heat.
For some, however, tooth sensitivity puts the happy idea of these things in the shade.
Read more in Andrew’s guest post on Compare The Treatment here.
With the Oral Health Foundation’s research into the UK population’s dietary habits revealing that 43% of adults are consuming one or more fruit juices or smoothies every day, Professor Andrew Eder considers the effect of such acidic beverages on the dentition.
Read the full article in Private Dentistry here:
Professor Andrew Eder explores the difference between physiological or pathological tooth wear, and considers why being able to differentiate between the two is so important for the long-term care of patients.
See the full article in BDJ In Practice here:
Tooth wear has hit the headlines at an almost unprecedent level, thanks to the efforts of a team at King’s College London, whose study into sipping acidic drinks such as fruit teas and flavoured water has shown they can damage the enamel.1
Commenting on the research, Professor Andrew Eder, a Specialist in Restorative Dentistry and Prosthodontics and Clinical Director of the London Tooth Wear Centre®, said, ‘This will come as little, if any surprise, to dentists. However, the fact that it has brought the issue into the public eye via media outlets such as the BBC2 and the Daily Mail3 is potentially of great benefit to the oral health of the nation, if dental teams can capitalise on this raised awareness in a timely manner.
‘It is an easy enough topic to bring up in conversation and may open up a further discussion about what patients can do to minimise such damage to the teeth. A suggested in the British Dental Journal article, asking a number of carefully framed questions may help to ascertain the extent of any given patient’s susceptibility to erosion.’
In this regard, O’Toole and Mullan suggest asking the following questions:
1. How many dietary acids are being consumed daily, including fruits, anything with a fruit flavouring, acidic drinks, acidic sweets and medications?
2. How many of these are between meals?
3. Is greater than 10 minutes being spent consuming any dietary acid at a single sitting?
4. Do they sip, swish, hold or rinse the dietary acid in their mouths prior to swallowing?
5. Do they consume dietary acids at an increased temperature, e.g. hot water with lemon, stewed fruits, fruit teas?1
If you consider that a patient may benefit from prevention-led intervention, simple steps that may help include:
• Limit the intake of acidic drinks to meal times
• Rinse the mouth with water for 15 to 30 seconds after consuming acidic drinks
• Chew sugarfree gum or eat a piece of cheese after consuming an acidic drink
• Wait at least an hour to brush teeth after consuming any acidic drinks
• Use a toothpaste that contains fluoride and a non-abrasive toothbrush to clean the teeth at least twice a day
• Use a fluoridated mouthwash every day at a different time to tooth brushing, as well as before or after acidic drinks, to help limit the erosive potential.
If you are concerned about any of your patients, the London Tooth Wear Centre® offers an evidence-based and comprehensive approach to managing tooth wear, using the latest clinical techniques and an holistic approach in a professional and friendly environment.
For further information on the work of the London Tooth Wear Centre®, please visit www.toothwear.co.uk, email email@example.com or call 020 7486 7180.
1.O’Tooole S, Mullan F. The role of the diet in tooth wear. British Dental Journal 2018: doi:10.1038/sj.bdj.2018.127
2. http://www.bbc.co.uk/news/health-43141587. Accessed 23 February 2018
3. http://www.dailymail.co.uk/news/article-5424729/Drinking-trendy-fruit-teas-ruin-smile.html. Accessed 23 February 2018