What is the cause of patients’ enamel loss?
Investigative process examines negative impact on oral health
A good friend of mine recently traveled to Hawaii for a
vacation and experienced a sting by a sea urchin. Unless
this happens to you or someone you know, it sounds very
mundane, right? Apparently, this spiny creature leaves the
spines deeply embedded in the foot or hand.
The best way to treat this happens to be a large pan of
vinegar that is used for several days as a soak. Soaking the
embedded spines, which are mostly calcium carbonate, in
vinegar dissolves them. Using a tweezer only causes the spines
to break off into smaller pieces. Eggs have
been used in science experiments to show
the dissolution of the shell in a jar of vinegar
liquid over a period of time (egg shells are
made of calcium carbonate as well). So, what
does this have to do with tooth erosion and
There is a trend right now to use vinegar
as a weight-loss technique. The person uses
a shot glass and consumes vinegar once or
twice a day. This is seen more often now in
the United States, but it has been practiced
in some countries for hundreds of years.
Some publications tout the use of vinegar
as being beneficial in controlling digestive
issues such as GERD. The idea presented is
that we do not produce enough acid as we
age, and the added vinegar adds to acid in
the GI tract to aid digestion.
Gastroenterologists do not promote
this treatment and warn patients about
using vinegar in this way. If the dental
professional notices thinning enamel, are we asking the
questions related to vinegar use as well as other causes
listed in this column?
Huysmans et al. (2011) describe both erosion and erosive
tooth wear: “Erosion is a partial demineralization of enamel
or dentine by extrinsic acids. Erosive tooth wear is the accel-
erated loss of dental hard tissue through the combined effect
of erosion and mechanical wear (abrasion and attrition).”
Bruxism falls into this category of mechanical wear. Any
acid below 5. 5 pH can dissolve the hydroxyapatite crystals
in enamel. GERD is known to produce dental erosion and
halitosis (Marsicano et al. 2013). Patients complaining of
halitosis should be questioned about GERD. The connection
with tooth enamel changes is often not evaluated in its
Erosive tooth wear has increased noticeably in children,
young adults, and adolescents during the past few decades.
At one time, soda consumption was not an issue, nor was
the bleaching craze in existence that we are witnessing in
recent years ( Willershausen
et al. 2014).
The combination of acidic food/beverage consumption with low pH, acidic
products used in the mouth,
bleaching of teeth, GERD,
bruxism, or disordered eating practices may be promoting a faster, more noticeable dissolution of the
When the enamel is softened by acidity, habits such as
bruxism, improper brushing, or even gastroesophageal issues
make the enamel less able to combat damage. The dietary
habits of society have changed as well. More fiber-rich, crunchy
foods are consumed, and when used on soft enamel, there is
more destruction of the tooth surface. Willershausen et al.
state that other foods contain vinegar as well, such as mustard,
ketchup, salad dressings, and pickles, to name a few.
NANCY W. BURKHART
EdD, is an adjunct
associate professor in the
Baylor College of
Dentistry and the Texas A
& M Health Science
Center, Dallas. Dr.
Burkhart is founder and
cohost of the International
Oral Lichen Planus
Support Group (dentistry.
coauthor of General and
Oral Pathology for the
Dental Hygienist. She was
awarded a 2016
American Academy of
Oral Medicine Affiliate
She was a 2006 Crest/
ADHA award winner. She
is a 2012 Mentor of
Philips Oral Healthcare
and Penn Well Corp. She
can be contacted at
Image of a patient with enamel loss.
Note the loss of dental anatomy in
Image of a radiograph with evident loss
of enamel in mandibular first molar.