Tooth wear in children: prevalence, presentation and prevention

Tooth wear in children is multifactorial and can be due to either physiological or pathological processes. The different types of tooth wear (erosion, attrition and abrasion) can occur separately or together, and often act synergistically. Erosion is the most frequently seen type of tooth wear in children in both the primary and permanent dentition. Physiological attrition is commonly seen in later stages of the primary dentition and is often accelerated by erosion.¹

Prevalence

The prevalence of tooth wear in children is high, with the 2013 Child Dental Health Survey finding more than 50% of 5 year olds had signs of tooth wear and nearly 40% of 15 year olds.² Around 4% of 15 year olds had tooth wear extending into dentine or pulp on lingual surfaces of the incisors, and 3% extending into dentine or pulp on the occlusal surfaces of molars.² While low proportions of children were affected by tooth wear into dentine or pulp, this is very substantial damage to have at the age of 15 years. This prevalence level has been validated in a previous systematic review that estimated an overall worldwide prevalence of tooth erosion of 30% in the permanent dentition of children and adolescents aged 8–19 years.³

Aetiology

The aetiology of tooth wear in children is varied, and it is important therefore to take a thorough medical and dietary history when tooth wear is found, as well as a full interrogation of oral hygiene practices and habits.⁴

Erosive tooth wear in children may be from acids of intrinsic or extrinsic origin. The intrinsic source is gastric acid and may be caused by gastro-oesophageal reflux disease (GORD),⁵ frequent vomiting due to medical conditions such as cyclic vomiting syndrome⁶ (Figure 1), or self-induced vomiting associated with eating disorders, such as anorexia and bulimia.^7,8 Tooth wear due to GORD is much less common in children compared to adults, but factors such as obesity and neuro-disability increase the risk.^9–12 The average onset of eating disorders is early teens, but may occur in younger children. Bulimia is more often seen in older adolescent girls, but increasing numbers of boys with the condition are being reported.¹⁴

Most studies in children suggest that the most common cause of erosive tooth wear is from dietary factors, particularly drinks.^14–16 Foods and drinks with an inherent pH below 5.5, taken frequently, are likely to cause erosive damage to teeth, but there is not a critical pH that can be cited, as erosive potential is affected by other components in foods and drinks, such as mineral content, buffers and temperature.^17–19

The timing of toothbrushing in relation to the consumption of foods and drinks with erosive potential or brushing after vomiting may be important.²⁰ Studies have shown that toothbrushing can cause abrasive tooth wear if carried out soon after an acidic challenge.^21,22

Attrition due to tooth-to-tooth contact is less common in children, but may be seen in the primary dentition as a purely physiological process, especially in upper primary incisors, and may be accelerated by erosive challenges such as frequent acidic drinks (Figure 2). Attrition is more commonly seen in children with neurological disabilities where tooth grinding is habitual. In general, physiological tooth wear occurs slowly and is unlikely to cause acute symptoms, whereas pathological tooth wear often occurs more rapidly, and issues may include sensitivity, loss of tooth tissue and pulpal exposure.

Presentation of tooth wear in children

Presentation of tooth wear in children is similar to that in adults, but with erosion being the most common type of wear seen. It commonly affects the maxillary teeth, with translucent incisal edges, and if drinking habits are involved, isolated areas of the mouth can be affected.²³ Erosion from intrinsic sources will often affect the palatal surfaces of teeth, but patterns may vary where gastric content pools, or when vomiting is followed by toothbrushing. It is common in severe erosion to see a rim of enamel around gingival margins that has been spared due to the protective effect of alkaline crevicular fluid. In children in the mixed dentition, erosion may be diagnosed early, but if preventive measures are not effective, then early progression in the permanent dentition can be spotted on the mesio-buccal cusp of lower first permanent molars (Figures 3 and 4).²⁴

Abrasion is not often seen in paediatric populations because it is usually due to a repetitive external habit, such as pen lid chewing. Attrition is usually a physiological process, often accelerated by erosion.²⁵

Diagnosis and history taking

When examining young children, as well as monitoring for caries, it is important to look out for signs of tooth wear to prevent progression into the permanent dentition. A thorough history should include a review of medical and dietary histories.²⁶ If a child has a history of GORD, questions should be asked about anti-reflux medications, frequency of indigestion and heart burn, and any symptoms despite taking medication. If an eating disorder is suspected, then sensitive questioning needs to be carried out, particularly in teenagers who may not have disclosed their condition to parents/carers. In patients with clear intrinsic erosive pattern of tooth wear, with an unclear diagnosis, referral to the patient's GP or to a gastroenterologist may be appropriate.²⁴

Dietary histories should include questions about any erosive foods and drinks ingested. For paediatric patients, it is helpful to ask whether they drink milk and/or water, and if not, then any other drinks consumed are likely to be of erosive potential.¹⁵ Questions regarding frequency of intake of drinks, mode of drinking (bottle, feeder cup, glass, sports bottle, with/without a straw) and any other habits, such as holding or swishing drinks in the mouth.^15,16,26

Knowing the timing of toothbrushing may also be helpful, especially if a child vomits regularly or has frequent acidic drinks, particularly before or at bedtime. If a child presents with attrition, then questions regarding grinding, especially at night, temporomandibular joint pain and facial muscle pain are helpful to ask.

Monitoring

When children show signs of tooth wear, it is important to monitor it so that any progression can be reviewed, and to assess whether preventive advice has been followed. Children with active erosive tooth wear may suffer from sensitivity, which may be helped with preventive or restorative treatments, but reoccurrence of sensitivity may indicate that compliance with preventive advice has lapsed. Indices, such as BEWE, can be used to record severity of tooth wear, but this is less useful in the primary and mixed dentitions.²⁷ Clinical photographs are probably the most useful monitoring tool. They can be uploaded to electronic patient records and viewed easily at recall examinations.

Prevention

Prevention is the key measure to either prevent or limit the progression of tooth wear. Education of paediatric patients and their parents on the potential dangers of frequent consumption of acidic foods and drinks is important, but can be complicated when giving concurrent advice regarding caries prevention. This is particularly the case when discussing drinks, which, for caries prevention would be around the limitation of sugar-containing drinks. Many clinicians will adopt the practice of product substitution, for example exchanging a sugary drink for the sugar-free, or low sugar alternative. This may be appropriate for caries prevention, but it should be remembered that many sugar-free drinks are still acidic and hence, have high erosive potential. Chapter 7 of Delivering Better Oral Health has a useful table (7.1) with risk factors for tooth wear and advice to give for each risk.²⁸ For both caries and erosion prevention, the only truly safe drinks are water and milk.²⁹ Studies on carbonated mineral waters are inconclusive, with some studies showing that they may be protective against erosion while others show potential damaging effects.^20,30 Other researchers have suggested that flavoured carbonated waters showed appreciable titratable acidity and should be considered potentially erosive.³¹ Tea and coffee, with or without milk are unlikely to cause erosion, but fruit teas are acidic and will contribute to erosion if used frequently. The addition of fluoride to fruit teas may reduce the erosive effect.^29,32 Other herbal teas without the addition of fruit, such as chamomile, may be safer.

There is anecdotal evidence that acidic drinks served at lower temperatures and with ice will reduce the erosive potential of the drink by altering the titratable acidity, but heating drinks has been shown to increase the erosive potential.³³

The erosive potential of drinks can also be reduced by preventing or ceasing drinking habits such as holding or swishing/frothing drinks in the mouth, advising against the frequent use of feeder cups or putting acidic drinks in sports bottles, and the correct use of straws.^15,34 Straws can be helpful to direct drinks to the back of the mouth to avoid the teeth. Video fluoroscopy has shown the best kind of straw to avoid reflux into the mouth is a narrow-bored straw placed at the back of the mouth, and definitely not used to suck drinks through the teeth (Figure 5).³⁵

Toothbrushing

Toothbrushing should follow ‘Delivering Better Oral Health’ advice, brushing twice a day with a fluoride toothpaste and ‘spit, don't rinse’.²⁸ For children with sensitivity, it can be helpful to run the toothbrush under warm water before applying toothpaste to soften the bristles. The use of toothpastes marketed for sensitive teeth, containing ingredients such as potassium nitrate, strontium chloride or CPP-ACP have been found to be useful in reducing symptoms.^36,37 In terms of timing of brushing, most studies have shown that it is beneficial not to brush straight after an acidic challenge (such as vomiting, or drinking a glass of fresh orange juice), but the effect can be mitigated by the use of a high-fluoride toothpaste where appropriate.^20–22

Fluoride

The use of fluoride toothpaste has been shown to be effective in helping to prevent tooth wear by improving the resistance of enamel to acid attack and it can also help reduce sensitivity. Studies have shown that the use of a high-fluoride toothpaste will reduce enamel loss during an acidic challenge.³⁸ Children diagnosed with tooth wear due to erosion should be using at least a 1450ppm fluoride toothpaste and, where appropriate, higher-fluoride content toothpastes can be prescribed.²⁸ Fluoride varnish application will also be helpful in reducing sensitivity and improving enamel resistance.

Challenges to giving dietary advice to children and adolescents

Over the past 20–30 years lifestyles have changed considerably and with this diets have also modified.^39,40 Teenagers do not ‘graduate’ onto drinking coffee and tea, and studies have shown that 73% of pre-school and 50% of infant school children do not drink water.⁴¹ Many children receive between 30% and 50% of their total daily calorific intake from soft drinks alone.⁴² These children are potentially conditioned from an early age to the sweet taste of drinks with no nutritional benefit.

One of the biggest challenges when giving dietary advice for preventing tooth wear in the paediatric population, especially erosive tooth wear, is overcoming the power of the soft drink industry in terms of influence and marketing of these beverages. The challenges are similar for those when giving advice for caries prevention and general health advice, such as prevention of obesity and type II diabetes. Both children and adults can be heavily influenced by advertising and peer pressure, and in that respect, the soft drink industry has been successful.

The soft drink industry in the UK has a market value of £16 billion, with the largest sector being carbonated drinks (40%). In 2021, the soft drink consumption in the UK was 14,520 million litres, an average of 105 litres per person per year. There has been a year-on-year increase in growth of the energy drink sector (8.4% in 2021), and in 2021, fruit juice consumption was down by 5%.⁴³ Water consumption has increased by 10% since 2012, with the fastest growing category being bottled water. With 37 litres per person per year of bottled water consumed, we are far behind our European counterparts who are consuming 118 litres per year.⁴⁴ This market is not restricted to the UK. The global soft drink market is worth $840.6 billion, with 45% of this being carbonated soft drinks, with Coca-Cola Co and Pepsi Co Inc holding 70% of the US carbonated soft drink market.⁴⁵ The power of the Coca-Cola brand is far reaching. It is the world's fifth most valuable brand at $81.6 billion, and is the second most understood term in the world after ‘OK’. It is used often for sponsoring, both partly sponsoring the London Olympics in 2012 and the London Eye from 2015 to 2020. The ‘Share-a Coke’ advertising campaign led to a 5% volume growth of sales.

Energy and sports drinks have increased in consumption since 2015. While sports drinks have recently decreased in popularity, the consumption of energy drinks has increased, and they now have an 88% share of this market. A Guardian article in 2018 stated that UK children consume energy drinks at a higher rate than those of any other country with 20% of 10-year-old children having them regularly.⁴⁶ While initially marketed for ‘young adults as a cheap and legal staple for staying up all night to study or rave into the small hours’, they are now consumed mainly by younger children. When interviewed, one 10–11-year-old boy was quoted as saying that he thought ‘boys looked proper rock hard when having these drinks in front of girls’ and another girl of the same age said ‘if a friend has something nice like an energy drink and you just have a bottle of water they look much cooler’. This phenomenon has become much more high profile since the energy drink ‘Prime’ became a sensation after being launched by YouTubers KSI and Logan Paul in 2022. The drink, which is essentially 10% coconut water and the rest water (with some added branch-chain amino acids, antioxidants and electrolytes), was being sold out in minutes in supermarkets, leading to limited availability in the UK. Customers were queuing outside stores before dawn and jostling other shoppers, and even diving into display cabinets to get the product. Owing to shortages of supply, the £1.99 bottles were then being offered for sale online, in some places for up to £10,000.^47,48

Sour sweets have also become popular in recent years. The risks associated with the consumption of lemon and sour sweets for erosive tooth wear have been shown, particularly if taken frequently over a long period of time.^49,50 The way in which sweets are given to children has changed, with parents reporting vagueness regarding consumption habits.⁵¹ Permissiveness about limits for sweet eating has diluted any concept of them being an occasional treat. Parents have lack of familiarity with novelty sweets, and may be unaware of the damage they may do to teeth. Their low cost, easy availability, high sugar content and acidity are a cause for concern.

Another hidden danger for tooth health is vaping, which is becoming increasingly popular with children. One study has shown that 84% of undiluted vape samples had a pH of below 5.5. Labelling is not detailed, and pH cannot be predicted by flavour – flavours that might not be considered acidic, like vanilla, had a pH of 4.7–5.6.⁵²

Restorative management

Preventive and restorative management of erosive tooth wear in children is well described in the Royal College of Surgeons Clinical guideline for dental erosion.²⁴ The emphasis is on prevention, and limitation of progression of tooth wear. Where restorative management is needed for either symptoms or aesthetics, then direct composite restorations are generally the best option in children and adolescents (Figure 6).^53–58 For more advanced tissue loss in older children, laboratory-constructed composite veneers can be very effective (Figure 7).

Attrition rarely needs to be treated restoratively in children, but if temporomandibular joint issues persist, a soft splint for night-time wear can be helpful.

Conclusion

Patient compliance can only be achieved if children and their parents/carers are made fully aware and understand the causes and consequences for tooth wear. It will require significant lifestyle changes, and management of social and peer pressure to change behaviours. The difficulties in achieving this should not be underestimated, and parents and carers will need advice, encouragement and support.

The extent of the complexities in overcoming dietary and lifestyle changes can be neatly summarized in an infographic produced by Oxfam International (Figure 8), which illustrates the control large corporations have over individual spending habits.^59,60 This infographic shows that only 10 global companies have control over almost everything an individual consumer buys. This, together with powerful advertising and social media influencers, make this a far from easy task.