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Clinical Oral Investigations

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14.10.2020 | Review

Does delayed toothbrushing after the consumption of erosive foodstuffs or beverages decrease erosive tooth wear? A systematic review and meta-analysis

verfasst von: Deng-wei Hong, Xiu-jiao Lin, Annette Wiegand, Hao Yu

Erschienen in: Clinical Oral Investigations | Ausgabe 12/2020

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Abstract

Objective

Controversy exists regarding the effectiveness of delayed toothbrushing in decreasing erosive tooth wear (ETW). The purpose of this systematic review and meta-analysis was to assess the effects of delayed toothbrushing on ETW.

Materials and methods

This systematic review and meta-analysis was conducted according to the PRISMA statement and registered in PROSPERO (CRD42020200463). PubMed, Embase, and Web of Science databases were systematically searched with no publication year limits. Screening and data extraction were performed independently by two reviewers. In situ and in vitro studies comparing ETW after delayed and immediate toothbrushing following an erosive attack were included. Review Manager software 5.3 (The Cochrane Collaboration, Oxford, UK) was used for statistical analyses. Heterogeneity was assessed with the Cochran Q test and I² statistics.

Results

Of the 565 potentially relevant studies, 26 full-text articles were assessed for eligibility. Twelve articles were included in the systematic review, and 11 were included in the qualitative analyses. No significant difference in the ETW of human enamel was observed between delayed and immediate toothbrushing (P = 0.13), whereas significantly less ETW of bovine enamel was observed after delayed toothbrushing (P < 0.001). No significant difference in the ETW of bovine dentin was observed between delayed and immediate toothbrushing (P = 0.34). Studies on human dentin were not available. Subgroup analyses revealed a significant contribution of the use of fluoridated toothpaste to decreasing the ETW of human enamel after erosion and toothbrush abrasion (P = 0.02).

Conclusions

Bovine and human teeth behaved differently in response to erosion and toothbrush abrasion. Delayed toothbrushing after an erosive attack was not effective at decreasing the ETW of human enamel compared to immediate toothbrushing, whereas it was effective at decreasing the ETW of bovine enamel.

Clinical relevance

Delayed toothbrushing alone after the consumption of erosive foodstuffs or beverages is not capable of preventing erosive enamel wear.

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Lussi A, Schlueter N, Rakhmatullina E, Ganss C (2011) Dental erosion - an overview with emphasis on chemical and histopathological aspects. Caries Res 45:2–12. https://doi.org/10.1159/000325915 CrossRefPubMed

Schlueter N, Amaechi BT, Bartlett D, Buzalaf MAR, Carvalho TS, Ganss C, Hara AT, Huysmans MCD, Lussi A, Moazzez R (2020) Terminology of erosive tooth wear: consensus report of a workshop organized by the ORCA and the Cariology Research Group of the IADR. Caries Res 54:1–5. https://doi.org/10.1159/000503308

Lussi A (2006) Erosive tooth wear–a multifactorial condition of growing concern and increasing knowledge. Monogr Oral Sci 25:1. https://doi.org/10.1159/000093343

Richards W, Filipponi T, Roberts-Burt V (2014) Summary of mind the gap! A comparison of oral health knowledge between dental, healthcare professionals and the public. Br Dent J 216:188–189. https://doi.org/10.1038/sj.bdj.2014.126 CrossRef

Chu CH, Pang KKL, Lo ECM (2010) Dietary behavior and knowledge of dental erosion among Chinese adults. BMC Oral Health 10:13. https://doi.org/10.1186/1472-6831-10-13 CrossRefPubMedPubMedCentral

Al-Ashtal A, Johansson A, Omar R, Johansson AK (2015) Awareness and knowledge of dental erosion among Yemeni dental professionals and students. BMC Oral Health 15:119. https://doi.org/10.1186/s12903-015-0103-x CrossRefPubMedPubMedCentral

Hong DW, Lin XJ, Wiegand A, Yu H (2020) Knowledge of and attitudes towards erosive tooth wear among students of two Chinese universities. BMC Oral Health 20:1–9. https://doi.org/10.1186/s12903-020-01105-7 CrossRef

Attin T, Knofel S, Buchalla W, Tutuncu R (2001a) In situ evaluation of different remineralization periods to decrease brushing abrasion of demineralized enamel. Caries Res 35:216–222. https://doi.org/10.1159/000047459 CrossRefPubMed

Jaeggi T, Lussi A (1999) Toothbrush abrasion of erosively altered enamel after intraoral exposure to saliva: an in situ study. Caries Res 33:455–461. https://doi.org/10.1159/000016551 CrossRefPubMed

10.

Carvalho TS, Colon P, Ganss C, Huysmans MC, Lussi A, Schlüter N, Schmalz G, Shellis RP, Tveit AB, Wiegand A (2015) Consensus report of the European Federation of Conservative Dentistry: erosive tooth wear—diagnosis and management. Clin Oral Investig 19:1557–1561 CrossRef

11.

Zero DT, Lussi A (2006) Behavioral factors. Monogr Oral Sci 20:100–105. https://doi.org/10.1159/000093356 CrossRefPubMed

12.

Pinto SCS, Batitucci RG, Pinheiro MC, Zandim DL, Spin-Neto R, Sampaio JEC (2010) Effect of an acid diet allied to sonic toothbrushing on root dentin permeability: an in vitro study. Braz Dent J 21:390–395 CrossRef

13.

Ponduri S, Macdonald E, Addy M (2005) A study in vitro of the combined effects of soft drinks and tooth brushing with fluoride toothpaste on the wear of dentine. Int J Dent Hyg 3:7–12 CrossRef

14.

Ganss C, Schlueter N, Friedrich D, Klimek J (2007) Efficacy of waiting periods and topical fluoride treatment on toothbrush abrasion of eroded enamel in situ. Caries Res 41:146–151. https://doi.org/10.1159/000098049 CrossRefPubMed

15.

Attin T, Buchalla W, Putz B (2001b) In vitro evaluation of different remineralization periods in improving the resistance of previously eroded bovine dentine against tooth-brushing abrasion. Arch Oral Biol 46:871–874. https://doi.org/10.1016/S0003-9969(01)00039-5 CrossRefPubMed

16.

Attin T, Siegel S, Buchalla W, Lennon AM, Hannig C, Becker K (2004) Brushing abrasion of softened and remineralised dentin: an in situ study. Caries Res 38:62–66. https://doi.org/10.1159/000073922 CrossRefPubMed

17.

Buzalaf MAR, Hannas AR, Kato MT (2012) Saliva and dental erosion. J Appl Oral Sci 20:493–502. https://doi.org/10.1590/s1678-77572012000500001 CrossRefPubMedPubMedCentral

18.

Attin T, Buchalla W, Gollner M, Hellwig E (2000) Use of variable remineralization periods to improve the abrasion resistance of previously eroded enamel. Caries Res 34:48–52. https://doi.org/10.1159/000016569 CrossRefPubMed

19.

Hara AT, Pedroso TC, Teixeira ÉCN, Serra MC, Cury JA (2004) Abrasive wear on eroded root dentine after different periods of exposure to saliva in situ. Eur J Oral Sci 111:423–427. https://doi.org/10.1034/j.1600-0722.2003.00074.x CrossRef

20.

Lussi A (2006) Dental erosion: from diagnosis to therapy. Karger Medical and Scientific Publishers, Basel CrossRef

21.

Buzalaf MAR, Magalhães AC, Rios D (2018) Prevention of erosive tooth wear: targeting nutritional and patient-related risks factors. Br Dent J 224:371–378. https://doi.org/10.1038/sj.bdj.2018.173 CrossRefPubMed

22.

Is brushing teeth after eating good for you. https://www.colgate.com/en-us/oral-health/basics/brushing-and-flossing/is-brushing-teeth-after-eating-good-for-you-0313

23.

Bartlett DW, Lussi A, West NX, Bouchard P, Sanz M, Bourgeois D (2013) Prevalence of tooth wear on buccal and lingual surfaces and possible risk factors in young European adults. J Dent 41:1007–1013. https://doi.org/10.1016/j.jdent.2013.08.018 CrossRefPubMed

24.

Toole SO, Bernabé E, Moazzez R, Bartlett D (2017) Timing of dietary acid intake and erosive tooth wear: a case-control study. J Dent 56:99–104. https://doi.org/10.1016/j.jdent.2016.11.005

25.

Shellis RP, Featherstone JDB, Lussi A (2014) Understanding the chemistry of dental erosion. Erosive Tooth Wear 25:163–179 Karger Publishers, Basel

26.

Eisenburger M, Addy M, Hughes JA, Shellis RP (2001) Effect of time on the remineralisation of enamel by synthetic saliva after citric acid erosion. Caries Res 35:211–215. https://doi.org/10.1159/000047458 CrossRefPubMed

27.

Shellis RP, Featherstone JDB, Lussi A (2014) Understanding the chemistry of dental erosion. Monogr Oral Sci 25:163–179. https://doi.org/10.1159/000359943 CrossRefPubMed

28.

Lopes PM, da Silva JSA, João-Souza SH, Maximiano V, Machado AC, Scaramucci T, Aranha ACC (2020) Enamel surface loss after erosive and abrasive cycling with different periods of immersion in human saliva. Arch Oral Biol 109:104549. https://doi.org/10.1016/j.archoralbio.2019.104549 CrossRefPubMed

29.

Wiegand A, Wegehaupt F, Werner C, Attin T (2007) Susceptibility of acid-softened enamel to mechanical wear–ultrasonication versus toothbrushing abrasion. Caries Res 41:56–60 CrossRef

30.

Lussi A, Lussi J, Carvalho TS, Cvikl B (2014) Toothbrushing after an erosive attack: will waiting avoid tooth wear? Eur J Oral Sci 122:353–359. https://doi.org/10.1111/eos.12144 CrossRefPubMed

31.

Moher D, Liberati A, Tetzlaff J, Altman DG, Group P (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6:e1000097 CrossRef

32.

Yang H, Xu YL, Hong G, Yu H (2020) Effects of low-temperature degradation on the surface roughness of yttria-stabilized tetragonal zirconia polycrystal ceramics: a systematic review and meta-analysis. J Prosthet Dent: epub ahead of print. https://doi.org/10.1016/j.prosdent.2020.01.005

33.

Higgins JP, Green S (2019) Cochrane handbook for systematic reviews of interventions. https://training.cochrane.org/handbook

34.

Yu H, Chen Y, Cheng H, Sawase T (2019) Finish-line designs for ceramic crowns: a systematic review and meta-analysis. J Prosthet Dent 122:22–30. e5. https://doi.org/10.1016/j.prosdent.2018.10.002 CrossRefPubMed

35.

Bown MJ, Sutton AJ (2010) Quality control in systematic reviews and meta-analyses. Eur J Vasc Endovasc Surg 40(5):669–677 CrossRef

36.

Rios D, Honório HM, Magalhães AC, Delbem ACB, Machado MAAM, Silva SMB, Buzalaf MAR (2006) Effect of salivary stimulation on erosion of human and bovine enamel subjected or not to subsequent abrasion: an in situ/ex vivo study. Caries Res 40:218–223. https://doi.org/10.1159/000092229 CrossRefPubMed

37.

Ferreira MC, Ramos-Jorge ML, Delbem ACB, de Sousa VR (2013) Effect of toothpastes with different abrasives on eroded human enamel: an in situ/ex vivo study. Open Dent J 7:132–139 CrossRef

38.

Tsuda Y, Kitasako Y, Sadr A, Nakashima S, Tagami J (2016) Effects of brushing timing after erosive challenge on enamel loss in situ: white light interferometer and nanoindentation study. Dent Mater J 35:613–620. https://doi.org/10.4012/dmj.2015-405 CrossRefPubMed

39.

Steiger-Ronay V, Tektas S, Attin T, Lussi A, Becker K, Wiedemeier DB, Beyeler B, Carvalho TS (2019) Comparison of profilometric and microindentation analyses for determining the impact of saliva on the abrasion of initially eroded enamel. Caries Res 53:33–40. https://doi.org/10.1159/000489133 CrossRefPubMed

40.

Attin T, Buchalla W, Gollner M, Hellwig E (2000) Use of variable re mineralization periods to improve the abrasion resistance of previously eroded enamel. Caries Res 34(1):48–52 CrossRef

41.

Wegehaupt F, Gries D, Wiegand A, Attin T (2010) Is bovine dentine an appropriate substitute for human dentine in erosion/abrasion tests? J Oral Rehabil 35(5):390–394. https://doi.org/10.1111/j.1365-2842.2007.01843.x

42.

Rios D, Honório HM, Magalhães AC, Silva SMBD, Delbem ACB, de Andrade Moreira Machado MA, Buzalaf MAR (2008) Scanning electron microscopic study of the in situ effect of salivary stimulation on erosion and abrasion in human and bovine enamel. Braz Oral Res 22(2):132–138. https://doi.org/10.1590/s1806-83242008000200007

43.

Ranjitkar S, Rodriguez JM, Kaidonis JA, Richards LC, Townsend GC, Bartlett DW (2009) The effect of casein phosphopeptide–amorphous calcium phosphate on erosive enamel and dentine wear by toothbrush abrasion. J Dent 37(4):250–254. https://doi.org/10.1016/j.jdent.2008.11.013

44.

Wiegand A, Bichsel D, Magalhães AC, Becker K, Attin T (2009) Effect of sodium, amine and stannous fluoride at the same concentration and different pH on in vitro erosion. J Dent 37(8):591–595. https://doi.org/10.1016/j.jdent.2009.03.020

45.

Hara AT, Carlos GC, Creeth J, Zero DT (2008) The effect of human saliva substitutes in an erosion-abrasion cycling model. Eur J Oral Sci 116(6):552–556. https://doi.org/10.1111/j.1600-0722.2008.00575.x

46.

Navimipour EJ, Kimyai S, Nikazar S, Ghojazadeh M (2012) In vitro evaluation of the effect of delaying toothbrushing with toothpaste on enamel microhardness subsequent to bleaching the teeth with 15% carbamide peroxide. Oper Dent 37(1):87–92. https://doi.org/10.2341/11-030-L

47.

Navimipour EJ, Mohammadi N, Mostafazadeh S, Ghojazadeh M, Oskoee PA (2013) Effect of delaying toothbrushing during bleaching on enamel surface roughness: an in vitro study. Oper Dent 38(2):218–225. https://doi.org/10.2341/11-442-L

48.

Borges AB, Santos LFTF, Augusto MG, Bonfiette D, Hara AT, Torres CRG (2016) Toothbrushing abrasion susceptibility of enamel and dentin bleached with calcium-supplemented hydrogen peroxide gel. J Dent 49:54–59. https://doi.org/10.1016/j.jdent.2016.03.009

49.

Al-Mashhadani A, Plygkos I, Bozec L, Rodriguez JM (2016) Three-dimensional in vitro measurements of tooth wear using fluoridated dentifrices. Aust Dent J 61(3):304–309. https://doi.org/10.1111/adj.12372

50.

Dehghan M, Ozorio JV, Chanin S, Tantbirojn D, Versluis A, Garcia-Godoy F (2017) Protocol for measurement of enamel loss from brushing with an anti-erosive toothpaste after an acidic episode. Gen Dent 65(4):63–68 PubMed

51.

Yulong Z, Desheng Y, Fan X, Yanfeng L (2018) Effects of two toothpastes used at different time on enamel remineralization and acid resistance. Journal of clinical rehabilitative tissue engineering research 22(34):5490–5495. https://doi.org/10.3969/j.issn.2095-4344.0685

52.

Nehme M, Parkinson CR, Zero DT, Hara AT (2019) Randomised study of the effects of fluoride and time on in situ remineralisation of acid-softened enamel. Clin Oral Investig 23(12):4455–4463. https://doi.org/10.1007/s00784-019-02900-5

53.

Buedel S, Lippert F, Zero D, Eckert GJ, Hara A (2018) Impact of dentifrice abrasivity and remineralization time on erosive tooth wear in vitro. Am J Dent 31(1):29–33

54.

Saxer UP, Yankell SL (1997) Impact of improved toothbrushes on dental diseases. II. Quintessence Int 28:9. https://doi.org/10.1016/S0889-5406(99)70145-9 CrossRef

55.

Ganss C, Schlueter N, Preiss S, Klimek J (2009) Tooth brushing habits in uninstructed adults—frequency, technique, duration and force. Clin Oral Investig 13:203–208. https://doi.org/10.1007/s00784-008-0230-8

56.

Al-Dlaigan YH, Shaw L, Smith AJ (2002) Dental erosion in a group of British 14-year-old, school children. Part III: influence of oral hygiene practises. Br Dent J 192:526–530 CrossRef

57.

Philip N (2019) State of the art enamel remineralization systems: the next frontier in caries management. Caries Res 53:284–295. https://doi.org/10.1159/000493031

58.

Eisenburger M, Shellis RP, Addy M (2003) Comparative study of wear of enamel induced by alternating and simultaneous combinations of abrasion and erosion in vitro. Caries Res 37:450–455. https://doi.org/10.1159/000073399

59.

Lippert F, Parker DM, Jandt KD (2004) In situ remineralisation of surface softened human enamel studied with AFM nanoindentation. Surf Sci 553:105–114 CrossRef

60.

Garberoglio R, Cozzani G (1979) In vivo effect of oral environment on etched enamel: a scanning electron microscopic study. J Dent Res 58:1859–1865 CrossRef

61.

Hara AT, González-Cabezas C, Creeth J, Parmar M, Eckert GJ, Zero DT (2009) Interplay between fluoride and abrasivity of dentifrices on dental erosion-abrasion. J Dent 37:781–785. https://doi.org/10.1016/j.jdent.2009.06.006 CrossRefPubMed

62.

Schlueter N, Klimek J, Ganss C (2009) In vitro efficacy of experimental tin- and fluoride-containing mouth rinses as anti-erosive agents in enamel. J Dent 37:944–948. https://doi.org/10.1016/j.jdent.2009.07.010 CrossRefPubMed

63.

Hove LH, Holme B, Young A, Tveit AB (2007) The erosion-inhibiting effect of TiF4, SnF2, and NaF solutions on pellicle-covered enamel in vitro. Acta Odontol Scand 65:259–264. https://doi.org/10.1080/00016350701477581 CrossRefPubMed

64.

Schlueter N, Hardt M, Lussi A, Engelmann F, Klimek J, Ganss C (2009) Tin-containing fluoride solutions as anti-erosive agents in enamel: an in vitro tin-uptake, tissue-loss, and scanning electron micrograph study. Eur J Oral Sci 117:427–434. https://doi.org/10.1111/j.1600-0722.2009.00647.x CrossRefPubMed

65.

Levy SM (1994) Review of fluoride exposures and ingestion. Community Dent Oral Epidemiol 22:173–180 CrossRef

66.

Laurance-Young P, Bozec L, Gracia L, Rees G, Lippert F, Lynch RJM, Knowles JC (2001) A review of the structure of human and bovine dental hard tissues and their physicochemical behaviour in relation to erosive challenge and remineralisation. J Dent 39:266–272. https://doi.org/10.1016/j.jdent.2011.01.008 CrossRef

67.

Attin T, Wegehaupt F, Gries D, Wiegand A (2007) The potential of deciduous and permanent bovine enamel as substitute for deciduous and permanent human enamel: Erosion–abrasion experiments. J Dent 35:773–777. https://doi.org/10.1016/j.jdent.2007.07.007 CrossRefPubMed

68.

Karlinsey RL, Mackey AC, Blanken DD, Schwandt CS (2012) Remineralization of eroded enamel lesions by simulated saliva in vitro. Open Dentistry Journal 6(1):170–176. https://doi.org/10.2174/1874210601206010170

69.

Wang C, Li Y, Wang X, Zhang L, Tiantang FB (2012) The enamel microstructures of bovine mandibular incisors. Anat Rec (Hoboken) 295:1698–1706. https://doi.org/10.1002/ar.22543

70.

Bertassoni LE, Habelitz S, Kinney JH, Marshall SJ, Marshall GW (2009) Biomechanical perspective on the remineralization of dentin. Caries Res 43:70–77. https://doi.org/10.1159/000201593

71.

Fan Y, Sun Z, Moradian-Oldak J (2009) Controlled remineralization of enamel in the presence of amelogenin and fluoride. Biomaterials 30:478–483. https://doi.org/10.1016/j.biomaterials.2008.10.019

72.

Cao CY, Mei ML, Li QL, Lo ECM, Chu C (2015) Methods for biomimetic remineralization of human dentine: a systematic review. Int J Mol Sci 16:4615–4627. https://doi.org/10.3390/ijms16034615

73.

Goldberg M, Kulkarni AB, Young M, Boskey A (2011) Dentin: structure, composition and mineralization: the role of dentin ECM in dentin formation and mineralization. Front Biosci 3:711. https://doi.org/10.2741/e281

74.

Bertassoni LE, Habelitz S, Marshall SJ, Marshall GW (2011) Mechanical recovery of dentin following remineralization in vitro—an indentation study. J Biomech 44:176–181. https://doi.org/10.1016/j.jbiomech.2010.09.005

75.

Buzalaf MA, Kato MT, Hannas AR (2012) The role of matrix metalloproteinases in dental erosion. Adv Dent Res 24:72–76. https://doi.org/10.1177/0022034512455029 CrossRefPubMed

76.

Mazzoni A, Tjäderhane L, Checchi V, Di Lenarda R, Salo T, Tay FR, Pashley DH, Breschi L (2015) Role of dentin MMPs in caries progression and bond stability. J Dent Res 94:241–251. https://doi.org/10.1177/0022034514562833 CrossRefPubMedPubMedCentral

77.

West NX, Davies M, Amaechi BT (2011) In vitro and in situ erosion models for evaluating tooth substance loss. Caries Res 45:43–52. https://doi.org/10.1159/000325945 CrossRefPubMed

78.

Hall AF, Buchanan CA, Millett DT, Creanor SL, Strang R, Foye RH (1999) The effect of saliva on enamel and dentine erosion. J Dent 27:333–339. https://doi.org/10.1016/s0300-5712(98)00067-0 CrossRefPubMed

79.

Higgins JPT, Green S (2011) Cochrane handbook for systematic reviews of interventions version 5.1.0. The Cochrane collaboration; 2011

Titel: Does delayed toothbrushing after the consumption of erosive foodstuffs or beverages decrease erosive tooth wear? A systematic review and meta-analysis
verfasst von: Deng-wei Hong
Xiu-jiao Lin
Annette Wiegand
Hao Yu
Publikationsdatum: 14.10.2020
Verlag: Springer Berlin Heidelberg
Erschienen in: Clinical Oral Investigations / Ausgabe 12/2020
Print ISSN: 1432-6981
Elektronische ISSN: 1436-3771
DOI: https://doi.org/10.1007/s00784-020-03614-9

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Springer Medizin

Does delayed toothbrushing after the consumption of erosive foodstuffs or beverages decrease erosive tooth wear? A systematic review and meta-analysis

Abstract

Objective

Materials and methods

Results

Conclusions

Clinical relevance

Neu im Fachgebiet Zahnmedizin

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Springer Medizin

Abstract

Objective

Materials and methods

Results

Conclusions

Clinical relevance

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