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News Bulletin : ADA News Bulletin August 2010
28 AUGUST 2010 committee report EROSIVE TOOTH WEAR IN PROFESSIONAL WINE TASTERS Our understanding of occupational risks of wine tasting has been based on case reports and cohort studies. Furthermore, in vitro studies have provided insights into the mechanism of dental erosion. However, we are unaware of findings of large epidemiological studies investigating the prevalence of dental erosion in professional wine tasters. Publication of case reports in the late 1990s first raised awareness of potential occupational hazard for professional wine tasters. Chaudhry et al.16 described wine erosion on palatal surfaces of maxillary anterior teeth in a 52-year-old diabetic wine merchant, who had been tasting 30 wines per day over 23 years. The pattern of erosion resembled that of a bulimic patient and had resulted from holding wine on the dorsal surface of the tongue followed by rinsing around the palate. Interestingly, the progression of erosion halted after the individual retired seven years later. Gray et al.17 reported occurrences of both dentinal hypersensitivity and extensive erosion on buccal surfaces of posterior teeth in a healthy 38-year-old wine merchant, who had a history of tasting 20 wines per day over 10 years. The relationship between erosion and wine consumption was confirmed in a subsequent cohort study by Wiktorsson et al.,4 who also reported a weak association between salivary factors and wine erosion. The multifactorial aetiology of dental erosion in wine tasters can cause diagnostic dilemma to clinicians. Mandel18 described extensive erosion on occlusal, buccal and lingual surfaces of posterior teeth in a 56-year-old female office administrator, who had been taking antihypertensive and antihistamine medications known to cause xerostomia. Extensive erosive wear can also occur in professional wine tasters from vigorous toothbrushing immediately after wine tasting (Fig 1). This habit is not uncommon among wine tasters because of the problem with the belief that toothbrushing prevents extrinsic staining of teeth from wine tannins. Overall, existing reports on professional wine tasters indicate that dental erosion and dentinal hypersensitivity are associated with extended duration of wine tasting, presence of other risk factors for tooth wear and compromised host defence mechanisms. The onset for dentinal hypersensitivity varies from around five to 10 years after beginning the profession (unpublished data). However, not all wine tasters are affected, and social drinkers and recreational tasters are usually not at risk of wine erosion. Therefore, assessments should be made on an individual basis after giving careful consideration to overall risk factors for erosive tooth wear. RISK ASSESSMENT FOR EROSIVE TOOTH WEAR Risk assessment is an integral part of overall management of individuals at risk of erosive tooth wear, and it should comprise both comprehensive history-taking and thorough clinical examination. Both past and current history relating to wine tasting, medical conditions, diet, oral hygiene habits and use of erosion-inhibiting or remineralizing agents can provide information about future risk of erosive tooth wear. Erosive damage to teeth is generally related to the number and frequency of wine tasting, and wine judges and winemakers are at greatest risk. Underlying medical conditions associated with intrinsic erosion in these individuals may include hiatus hernia, gastric regurgitation, psychological problems (i.e., bulimia nervosa, anorexia nervosa, alcoholism, stress rumination) and morning sickness during pregnancy.12 In addition, common causes of extrinsic erosion are an acidic diet (such as citric fruits, fruit juices, acidic vegetables such as tomatoes, carbonated beverages, pickles and candies), medications (such as chewable vitamin C tablets, non-capsulated hydrochloric acid replacement, aspirin tablets, asthma medications or 'puffers', amino acid supplements and salivary stimulants), occupations requiring working in an acidic environment or fumes and sports (such as swimming in improperly chlorinated pools).10 The effect of these erosive risk factors can be exacerbated by tooth grinding (attrition), harsh toothbrushing habits (with use of abrasive dentifrice) and compromised salivary factors (as a result of dehydration, drug-induced hyposalivation, Sjogren's syndrome, radiotherapy for the head and neck area and surgical removal of salivary glands).19,20 Use of remineralizing agents (such as fluoride and CPP-ACP) can provide some protection against erosive demineralization and can assist in overall risk assessment. Clinical signs of early erosion are glazing and smoothing of enamel surface, with loss of micromorphological details. Advanced erosion lesions display gross loss of morphological details, rounding of cusps, loss of cervical convexity and proud restorations.14 Loss of enamel increases translucency of the incisal and proximal surfaces of anterior teeth, and the tooth may appear darker in shade as a result of shadowing of underlying dentine.14 On the occlusal and incisal surfaces of teeth, dentine exposure results in scooping and cupping of teeth. These clinical observations should be complemented with the assessment of both quality and quantity of salivary factors. Commercial saliva kits are available to test the resting pH value, flow rates and buffering capacity. However, some caution is needed in assessing salivary factors because salivary flow rate shows daily and yearly variations and is associated with the degree of the hydration of the body, body position, gland size and drug use.21 MANAGEMENT OF EROSIVE TOOTH WEAR Management of erosive tooth wear in wine tasters should conform the paradigm of minimal intervention philosophy, which emphasizes early detection and prevention before restorative approach is considered. Overall management of erosive tooth wear should include reduction of erosive demineralization as well as enhancement of remineralization of eroded lesions. Based on findings from previous in vitro and in situ, application of high concentration fluoride or CPP-ACP products is encouraged to remineralize eroded lesions. Fig 1. A photograph showing horizontal abrasion (scratch) marks on the labial surfaces of maxillary anterior teeth of a wine judge, who brushed vigorously and immediately after wine tasting sessions.
ADA News Bulletin September 2010