d e n t a l m a t e r i a l s 3 0 ( 2 0 1 4 ) 4349

Available online at www.sciencedirect.com

journal homepage: www.intl.elsevierhealth.com/journals/dema

Impact of erosive conditions on tooth-colored

restorative materials
Thomas Attin , Florian J. Wegehaupt
Clinic for Preventive Dentistry, Periodontology and Cariology, Center for Dental Medicine, University of Zurich,
Switzerland

a r t i c l e

i n f o

a b s t r a c t

Article history:

Objectives. To give an overview of the impact of erosive conditions on the behavior of tooth-

Received 30 May 2013

colored restoratives and performance of dental adhesives.

Received in revised form 8 July 2013

Methods. Acid-induced erosive lesions of enamel and dentin often need restorative pro-

Accepted 22 July 2013

cedures for rehabilitation. Nowadays, mostly tooth-colored restoratives (ceramics or resin

composites), which are adhesively xed to the dental substrate are used for this purpose.
In some cases it might be necessary to seal the exposed dentin before achieving this goal

Keywords:

in order to combat hypersensitivities and to protect those teeth from further erosive and

Erosion

abrasive loss. Moreover, it is conceivable that patients will fall back into their old erosive

Composite resin

behavior after the application of restoratives. The following overview describes in how far

Ceramics

intra-oral erosive conditions might affect the integrity of restorative materials, such as com-

Dental adhesives

posite resins and ceramics, or of dentin sealants. Additionally, the use of erosively altered
enamel and dentin as substrate for adhesive technologies is elucidated.
Results. In the literature, information of the behavior of tooth-colored restoratives under
still persisting erosive conditions are limited and mostly based on in vitro-studies. There
is information that the adhesion of dental adhesives to eroded dentin is compromised as
compared to regular dentin. The impact of erosive conditions relevant for the oral cavity on
ceramics and resin composites seems to be rather low, although only few clinical studies
are available.
Signicance. The review showed that erosive conditions might have only little impact on
behavior of tooth-colored restorative materials, such as composites and ceramics. Dentin
sealants also seem to be rather resistant against erosive conditions and might therefore
serve as an intermediary treatment option for exposed dentin surfaces. The adhesion of
dentin adhesives to eroded dentin might be increased by mechanical pre-treatment of the
substrate, but needs further investigation.
2013 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

1.

Introduction

Dental erosions are dened as loss of dental hard tissue due

to an attack of acidic substances, which might be additionally

modied by impact of proteolytic chemical degradation. Since

the etiology shows multiple reasons for the hard tissue
loss, the term biocorrosion was recently introduced in the
dental literature [1]. This term encompasses not only endogenous and exogenous acidic impacts, but also proteolytic

Corresponding author at: Plattenstr. 11, CH-8032 Zurich, Switzerland. Tel.: +41 44 634 3270; fax: +41 44 634 4308.
E-mail address: thomas.attin@zzm.uzh.ch (T. Attin).
0109-5641/$ see front matter 2013 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.dental.2013.07.017

44

d e n t a l m a t e r i a l s 3 0 ( 2 0 1 4 ) 4349

degradation of the teeth induced by proteases, such as pepsin,

from the gastric uid. Pepsin is able to destabilize the collagen network of the dentin. The acids responsible for the
demineralisation and loss of hard tissue substance might
stem from endogenous origin, stomach acid, or from exogenous sources from dietary compounds like acidic beverages or
food [2]. Although this new term biocorrosion was recently
introduced, the term erosion will still be used in the following, since it is more common.
The acid attack results in a loss of softening and demineralization of the tooth surface, which is prone to further abrasive
wear [3]. This means that two actions are responsible for the
erosively induced tooth wear observed in the oral cavity: (1)
The dissolution and loss of dental hard tissue, which is directly
induced by the acid attack. (2) The wear of the softened surface by mechanical impacts, such as toothbrushing, rubbing
with the tongue, tooth-to-tooth contacts or chewing of food.
Recently the term erosive tooth wear was coined for this
two-step chemicalmechanical process [4].
Analysis of epidemiological data has shown that the prevalence for erosively induced hard tissue loss with exposed
dentin amounts to about 23% in children and to 10% in adolescents [5]. In adults, distinct dental hard tissue loss due to
erosion or abrasion and attrition were found for about 3% of
the 20-year-olds and for up to 17% in the age group of 70 years
[6].
A recent study has shown that tooth erosion with low severity did does not impact oral health-related quality of life in
11- to 14-year-old children [7]. In contrast, adult patients with
non-cariogenic dental hard tissue loss has shown up with
reduced oral wellness due to compromised esthetic appearance of the teeth, reduced chewing efciency and tooth pain
due to the exposed dentin areas [8]. Also in this age group,
intensity of discomfort was related to the severity of the dental hard tissue loss. This means that in many cases protection
of the exposed dentin or restoration of the lost dental hard
tissues is necessary for oral rehabilitation of the dentition.
Clearly, before restoration of the teeth, abolishment of the
causative erosive factors have to be achieved. Thus, nutrition
control and/or medical and psychological treatment should be
applied, and patients have to be instructed about measures
how to prevent erosion [912].
The erosively induced loss of dental hard tissue often leads
to a reduction of the vertical dimension. Rehabilitation of
a severely worn dentition with loss of vertical dimension is
often associated with many difculties for the practitioner as
to follow an appropriate and stringent therapeutic strategy
[13].
The rehabilitations might be conducted using direct or
indirect restorative procedures [1421]. Nowadays, it should
be striven to save as much dental hard tissue as possible,
when restoring teeth. This minimal-interventional approach
is usually based on the use of adhesive technologies to x the
restorations properly to the erosively altered dental hard tissues. Thus, for restoring and protection of the worn dentition
composite restorative materials and ceramic restorations are
preferably used. Also, dentin sealants or desensitizers might
be applied to protect and seal exposed dentin areas. This procedures might be benecial at initial stages of hard tissue
loss or when nal restorations are not yet applicable. It might

be used in patients, in whom the anti-erosive strategies and

change of behavior have not been fully implemented.
As already mentioned, restorative procedures in patients
with erosions should be applied at best not before the achievement of these anti-erosive strategies and change of behavior.
However, in severe cases it might be necessary to even treat
the dentition e.g. with resin composite and simultaneously
eliminate the cause e.g. vomiting. This procedure might help
to combat hypersensitivities of affected teeth and to protect
the teeth from further erosive and abrasive loss. Moreover, it
is conceivable that patients will fall back into their old erosive behavior after the application of restoratives. Personal
observations in patients still suffering from chronic bulimia
after application of composite resin restorations give hint that
adhesively xed composite restorations may rapidly be disintegrated after a comparable short period of time (Figs. 13).
Thus it is important to know, how restorative materials
behave under still existing erosive conditions. Moreover, it
should be known, if special treatments of the eroded enamel
and dentin substrate are necessary for establishing a proper
adhesive xation of restorations and sealing materials.
The following review will describe in how far intra-oral
erosive conditions might affect the integrity of restorative
materials, such as composite resins and ceramics, or of dentin
sealants. Additionally, the use of erosively altered enamel
and dentin as substrate for adhesive technologies is elucidated.

1.1.

Composite restorative materials

Improvements of the composite restorative materials make

them suitable for direct and indirect restorative procedures
to rehabilitate worn dentitions [2225]. Laboratory studies
have shown that CAD/CAM designed ultrathin composite
occlusal veneers of 0.6 mm thickness yielded a decreased risk
of failure as compared to lithium disilicate ultrathin occlusal
veneers [26,27]. The use of ultrathin occlusal veneers might be
regarded as a conservative approach to treat erosive lesions,
with the aim to save as much dental hard tissue as possible.
Using composite for direct restorations allows for a minimally invasive treatment, only replacing the dental hard tissue
lost under the erosive conditions. Additionally, using direct
restorations might be regarded as an expectative approach
allowing to render the patient familiar with the new vertical dimension. Moreover, during this period anti-erosive
strategies might be implemented in the patients behavior. At later stages indirect restorations might be fabricated
[1719]. Numerous long-term studies document that composite restorations in posterior teeth behave well under
clinical conditions [2831]. Nevertheless, some studies showed
conicting results for extensive composite restorations with
cuspal coverage [21,32,33].
Recently, the results of a case series of six patients after an
average of 5.5 years of follow-up were published (Figs. 4 and 5).
In these patients a vacuum-formed matrix template was used
for reconstruction of the posterior vertical bite with composite resins [14]. The matrix was fabricated based on wax-up
models, allowing replacement of the missing vertical dimension avoiding freehand forming. This positive outcome of
using direct composite restorations was also recorded in an

d e n t a l m a t e r i a l s 3 0 ( 2 0 1 4 ) 4349

45

Figs. 4 and 5 Occlusal view of upper posterior composite

restorations after 5.5 years in service.

Figs. 13 Composite restorations in a patient still

suffering from bulimia after intra-oral service of one year
only. The restorations showed clear visible signs of
marginal disintegration with loss of restoration fragments.

investigation performed in a dental practice within a followup period of 6144 months [34].
Recently, the stamp technique for restoring erosively damaged teeth was described [35]. In this technique, a separate
silicone stamp is fabricated for each tooth on a wax-up model.
This stamp is used to apply the composite material onto the
tooth.
Beside this use of classical composite resins, also composite based materials for CAD/CAM-fabrication are suitable for
semi-direct restoration the worn dentition [16]. These materials, consisting of so-called hybrid ceramics or nano-composite
compositions, behave similarly or even better with respect to
two-body wear and toothbrushing wear than human enamel
[36].

Application of acidic products, such as acidulated uoride compounds may led to an increase in toothbrush wear
or loss of llers of composite resin restoratives [3739]. However, in most of these in vitro-models the composite resins
materials were subjected to an experimental long-term permanent exposure of up to 24 h to the uoridation products. It
is therefore not clear, in how far these observations might be
transferred to the clinical situation.
Only few studies have been dedicated to the question of
the behavior of composite resin materials under persisting
acidic and erosive conditions using dietary acids. In contrast
to glass-ionomer restoratives and polyacid-modied composite materials (compomers), hybrid and nano-hybrid composite
restorative materials have been shown to be resistant to acidic
attacks [4042]. Even under combined erosive and abrasive
conditions of toothbrushing wear, composite resin restoratives did not show higher wear than controls, which were
not subjected to an erosive-abrasive protocol [41]. Also, the
exposition of a hybrid composite to a 16 h permanent erosive
attack with hydrochloric acid (0.113%), phosphoric acid (0.02%)
or highly concentrated citric acid (5%) did not result in any
detectable damage of hybrid composite resin samples [42].

1.2.

Ceramics

Some papers have described the use of ceramic restorative

materials for reconstruction of excessively eroded and worn
dentition with complete reconstruction and increase of the
occlusal vertical bite [1720,43]. To the knowledge of the

46

d e n t a l m a t e r i a l s 3 0 ( 2 0 1 4 ) 4349

authors, no respective clinical follow-up study has been presented in dental literature as yet.
There is broad evidence that strong acidic compounds,
such as hydrouoric acid and acidulated phosphate uorides
(APFs) are able to etch the surface of both glass and feldspathic based ceramic materials [44]. This detrimental effect
of APF gels is already existent after a 4 min exposure of metalceramic and all-ceramic glass-based materials [45,46]. APF
gels are used for either uoridation regimes, but may also be
used for pre-treatment of glass-based ceramics in repairing
protocols [47,48]. In the case of hydrouoric acid, its etching
property is used in the pre-treatment of glass-based and feldspathic ceramic restorations before adhesive luting to dental
hard tissues.
Studies, which have dealt with the inuence of dietary
acids on dental ceramics are rare. The effect of carbonated beverage on wear of various ceramics was tested in a model using
enamel specimens as antagonists. The intermittent immersion to Coca-Cola of the enamel/ceramic samples resulted
in dissimilar wear characteristics of the different ceramic
materials [49]. The abrasive wear of the tested CAD/CAM
machinable ceramic (Vita Mark II, Vita Zahnfabrik, Bad Sckingen, Germany) and of the hydrothermal low-fusing veneering
ceramic (Duceram LFC, Ducera Dental, Rosbach, Germany)
was increased when intermittently immersed in the acidic
beverage as compared to water-stored controls. In contrast,
the wear of ne-particle-size porcelain (Vitadur Alpha) with
intermittent exposure to the beverage was found to be less
than its wear in water only. This observation was explained
with the fact that the wear resistance of the enamel opponent
was lower for the Vitadur Alpha porcelain than for the other
ceramics, thus reducing the impact of the softened enamel
on the Vitadur Alpha samples. In contrast to these ndings,
it was shown that immersion of a heat-pressed ceramic (IPS
Empress, Ivoclar Vivadent, Schaan, Liechtenstein) in 2% citric
acid for 8 h did not lead to roughening of the surface. In the
same study, 32-min-contact of the ceramic with a 1.23% APF
gel led to increased surface roughness.
This observed resistance of ceramics against simulated
erosive attacks, was also reported in a 24-h simulation of vomiting using articial gastric acid (pH: 1.2) [50]. In this study,
also no impact of the acidic attack on surface roughness of
different ceramic restoratives was detectable.

1.3.

Dentin sealants

Using dentin sealants and adhesives have been advocated

to be effective in reducing hypersensitivity of exposed erosively altered dentin and in protection of the dentin for further
acidic induced hard tissue loss [51]. In vitro- and in situexperiments have proved that resin-based dentin sealants
and dental adhesives were able to withstand erosive and
erosive/abrasive wear of both enamel and dentin [5254]. A
recently published in vitro-study could show that a resinbased surface sealant was able to maintain a dentin protective
effect under erosive/abrasive conditions, simulating an 8month in vivo-situation [55]. Also, even under severe erosive
clinical conditions, coating of eroded palatal tooth surfaces
with a resin-based adhesive has shown to have the potential to prevent further tooth wear. A clinical study has proved

protection for a limited period of up to 69 months [56]. In

contrast to these ndings, a non-resin-based desensitizer was
not effective in protecting dentin from erosive/abrasive wear
under simulated clinical conditions [57].
All above-mentioned studies have shown that the protective effect of surface sealants is limited in terms of time and
that a re-sealing is necessary to maintain the protective effect.
Comparing different pre-treatment modalities of the previously sealed and erosive-abrasively stressed dentin has shown
that there is no signicant difference in the mechanical stability and anti-erosive potential if previously sealed dentin was
either pre-treated with ethanol, a silane-coupling agent, sandblasting or remained untreated before re-sealing [58]. This
means that no additional pre-treatment of previous sealed
dentin is necessary to establish a new protective and stable
sealant layer on previously sealed dentin.
In a severely damaged dentition several dentin surfaces
might need a sealant application. This means that application and light-curing of the resin-based material would
be time-consuming. A recent study could prove that lightcuring duration of the resin-based sealant might be reduced
if simultaneously the light-curing intensity is increased,
thereby maintaining the total applied energy density [59]. This
approach showed up with no negative inuence on the permeability (anti-erosive effect) and the stability of the tested
surface sealants.

1.4.
Erosively altered enamel and dentin as bonding
substrate
The de- and remineralisation erosive processes and the exposition of the exposed dentin to the oral cavity in severe
erosive cases may lead to a sclerotic dentin substrate with a
hypermineralized shiny surface layer, tubular occlusion and
different mineral composition of the outermost dentin layer
as compared to natural sound dentin [60]. Eroded enamel
comes up with a supercially softened layer, with exposed
enamel prisms similar to the etching pattern seen after use of
enamel conditioning with phosphoric acid for adhesive bonding of dental adhesives [3]. It is known that the efcacy of
dentin adhesives to sclerotic dentin is reduced for most of the
dentin adhesives [60]. For enamel, no information is available,
whether eroded enamel tissue behaves different in terms of
efcacy of dental adhesives as compared to regular enamel.
However, it seems very likely that erosively etched enamel
might behave similar as enamel etched before application of
a dental adhesive during the conditioning process.
A possible approach to overcome problems with the adhesion to sclerotic dentin might be to prolong the application of
the phosphoric acid during the conditioning procedure, when
using etch-and-rinse adhesives [61,62]. A study investigating
this approach found a signicant increase in the microtensile
bond strength to sclerotically altered aged dentin, if the etching time before adhesive application was increased from 15
to 30 s [63]. In contrast, this nding was not corroborated in a
recent study also using a twofold increased acid etching time
before application of 3- and 2-step etch-and-rinse [64]. The
same nding was observed if the acidic adhesives of 2- and
1-step self-etching adhesives were applied two times longer
than demanded by the manufacture.

d e n t a l m a t e r i a l s 3 0 ( 2 0 1 4 ) 4349

Beside these chemical based approaches (increasing the

etching time or application time of adhesives) mechanical pre-treatments by roughening with a bur is advocated
to compensate the adverse properties of sclerotic dentin
[65,66]. In this sense, it was recently tested whether dentin
pre-treatment of articially eroded dentin by cleaning with
pumice, air abrasion, a silicon polisher, proxo-shape les or a
diamond bur before application of the adhesive systems might
be benecial in terms of adhesion [67]. This study showed that
a minimal roughening of the eroded dentin with a diamond
bur is recommended for long-term bonding to eroded dentin.
It was additionally conrmed that bond strength to eroded
dentin is reduced as compared to regular dentin.
To prevent erosive tooth wear the use of tin-containing uoride mouth rinse has shown very good results [6870]. This
mouth rinse leads to a stabilization of the eroded surface with
incorporation of tin into the eroded structure. It is conceivable
that use of such a mouth rinse might have an inuence on the
bond strength of dentin adhesives applied on eroded dentin
previously treated with this mouth rinse. In contrast to this
assumption, it was shown that bond strength of resin composite and an MDP-containing self-etching adhesive (Clearl
SE Bond, Kuraray, Tokyo, Japan) to eroded dentin was not
negatively inuenced by the treatment with a tin-containing
uoride mouth rinse [71]. Further studies by the same group
supported the hypothesis, that this effect might be due to a
bond promoting capacity of the MDP-adhesive system to tincompounds in the dental hard tissue being present after use
of the tin-containing uoride mouth rinse [72,73].

[6]

[7]

[8]

[9]

[10]

[11]

[12]

[13]

[14]

[15]

1.5.

Conclusions

The review showed that erosive conditions might have only

little impact of behavior of tooth-colored restorative materials, such as composites and ceramics. Dentin sealants also
seem to be rather resistant against erosive conditions and
might therefore serve as an intermediary treatment option
for exposed dentin surfaces. The adhesion of dentin adhesives to eroded dentin might be increased by mechanical
pre-treatment of the substrate, but needs further investigation.

[16]

[17]

[18]

[19]

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