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Dental Erosion Resulting from Chewable Vitamin C Tablets
C L IN IC A L 8. Taylor, J.F., and others. Kaposi’s sarcoma in Uganda: a clinicopathological study. Int J Cancer 8(1):122-135, 1971. 9. Dutz, W., and Stout, A.P. Kaposi’s sarcoma in in fants and children. Cancer 13(4):684-694, 1960. 10. Slavin, G., and others. Kaposi’s sarcoma in east f African children: a report of 51 cases. J Pathol 100(3):187-199, 1970. 11. Centers for Disease Control. Update on Kaposi’s sarcoma and opportunistic infection in pre viously healthy persons. MMWR 31(22):294, 1982. 12. Durach, D.T. Opportunistic infections and Kaposi’s sarcoma in homosexual men. New Engl J Med 305(24): 1465-1467,1981. 13. Gottlieb, M.S., and others. Pneumocystis V carinii pneumonia and mucosal candidiasis in previ ously healthy homosexual men: evidence of a new acquired cellular immunodeficiency. N Engl J Med 305(24) :1425-1431, 1981. 14. Finkbeiner, W.E., and others. Kaposi’s sarcoma ' in young homosexual men. A histologic study with particular reference to lymph node involvement. Arch Pathol Lab Med 106(6):261-264, 1982. 15. Gottlieb, G.J., and Ackerman, A.B. Kaposi’s sarcoma: an extensively disseminated form in young homosexual men. Human Pathol 13(10):882-892, 1982. 16. Friedman-Kien, A.E., and others. Dissemi-
nated Kaposi’s sarcoma in homosexual males. Ann Intern Med 96(6):693-700, 1982. 17. Friedman-Kien, A.E. Disseminated Kaposi’s sarcoma in young homosexual men. J Am Acad Der matol 5(4):468-471, 1981. 18. Thomsen, H.K.; Jacobsen, M.; MalchowMoller, A. Kaposi’s sarcoma among homosexual men in Europe. Lancet 2:688, 1981. 19. Hymes, K.B., and others. Kaposi’s sarcoma in homosexual men: a report of eight cases. Lancet 2:598-600, 1981. 20. Gottlieb, G.J., and others. A preliminary com munication on extensively disseminated Kaposi’s sarcoma in young homosexual men. Am J Dermatopathol 3(2):111-114, 1981. 21. Masur, H., and others. An outbreak of com munity-acquired Pneumocystis carinii pneumonia: initial manifestation of cellular immune dysfunction. N Engl J Med 305(24):1431-1438, 1981. 22. Siegal, F.P., and others. Severe acquired immunodeficiency in male homosexuals, manifested by chronic perianal ulcerative herpes simplex le sions. N Engl J Med 305(24):1439-1444, 1981. 23. Sterak, D. Opportunistic infections and Kaposi’s sarcoma in homosexual men. N Engl J Med 305(24):1465-1467, 1981. 24. Friedman-Kien, A., and others. Kaposi’s sar coma and Pneumocystis pneumonia among homo
REPORTS
sexual men: New York City and California. MMWR 30(25):305-308, 1981. 25. Kornfeld, H., and others. T-lymphocyte sub populations in homosexual men. N Engl J Med 307(12):729-931, 1982. 26. Lozada, F.; Silverman, S., Jr.; and Conant, M. New outbreak of oral tumors, malignancies and infec tious disease strikes young male homosexuals. Calif Dent Assoc J 10(5):39-42, 1982. 27. Alper, R.A., and Wiggins, H.E. Hemorrhagic palatal lesion. J Oral Pathol 4(4):222-228, 1975. 28. Guarda, L.G., and others. Factor VIII in Kaposi’s sarcoma. Am J Clin Pathol 76(2):197-200, 1981. 29. Haverkos, H.W., and Curran, J.W. The current outbreak of Kaposi’s sarcoma and opportunistic in fections. CA 32(6):330-339, 1982. 30. Vieira, J., and others. Acquired immune defi ciency in Haitians. Opportunistic infections in previ ously healthy Haitian immigrants. N Engl J Med 308(3):125-129, 1983. 31. Centers for Disease Control. Hepatitis B virus vaccine safety: report of an inter-agency group. MMWR 31(34):465-467, 1982. 32. Farman, A.G., and Uys, P.B. Oral Kaposi’s sar coma. Oral Surg 39(2):288-296, 1975.
Dental erosion resulting from chewable vitam in C tablets John L. Giunta, DMD, MS
The use o f chew able vita m in C is shown to cause the p H o f sa liva to drop to a le v e l at w hich tooth enam el can lose calcium b y the fo rm a tio n o f calcium citra te complexes. A case is reported.
V
itamin C, L-ascorbic acid, which is used in excess in the form of fruit juices, raw fruits, and even cordials, is known to cause or be directly associated with human dental erosion.111 A correlation between supplemental vitamin C and dental erosion has also been suggested for vitamin C syrup,12 but not for tablets. With the recent popularity of the use of supplem ental vitam in C, prescribed either professionally or self-prescribed, the use of vitamin C in tablet form has in creased. Distributors are claiming that the tablets are delicious, fruit-flavored, and
chewable. However, there is no warning that chewing vitamin C tablets may be detrimental to teeth. What follows is a case report and discussion on the effects of chewable vitamin C on teeth and a plea that dental erosion of this type is prevent able.
Report of case A 30-year-old female had requested a second opinion about whether her teeth were eroded and what might be the probable cause. Her dentist had informed her that she had severe dental erosion that required restoration by full crowns on at least 12 teeth. She wanted to know the cause so that the process might be halted before proceeding with restorative den tistry. Currently, her teeth were painful to brush and she had been told to use a desensitiz ing toothpaste. Her medical history showed an eye muscle operation at age 5; at 25, infectious mononucleosis and an epigastric hernia; and previous allergies to grass and pollen. She took medicine for iron-deficiency anemia and for menstrual pain. When questioned about pills, she admitted taking vitamin supplements, in cluding chewable vitamin C tablets. The exam ination showed the patient to be healthy. In traoral examination showed that there were several posterior teeth with deficient tooth structure. In the maxilla, the occlusal surface and lin gual cusps were missing on the premolars and on the first molars, where the mesiolingual
cusp was the most affected. The buccal sur faces were normal. The second molar and the other teeth appeared unaffected. In the mandi ble, the occlusal surfaces and the buccal and lingual cusps on the premolars and the first molars were missing; the buccal enamel was more affected than the lingual. There was cup ping on the occlusal surfaces. The second molar and the other teeth appeared unaffected. The exposed dentin was deep yellow, smooth, and shiny. The left side of the mouth was more involved with the process than the right side
(Fig 1. 2). Oral hygiene was good and no caries was noted. R adiographs that the patient had brought were inconclusive because of their poor quality. No further radiographs were taken. The diagnosis was severe dental ero sion. Further questioning concerned the patient’s diet with specific reference to the use of citrus or acid-containing beverages. She drank one 12-oz can of a diet beverage each day, and had chewed three tablets of megadosage vitamin C (Aceribo-C) each day for the past three years. One month before her visit, she had changed brands (Acerola Chewable), but was still taking v ita m in C. She de n ie d reg urg ita tio n of stomach contents. There was no occupational exposure to acid. The patient was advised that the daily expo sure to multiple chewable vitamin C tablets was most likely a major contributing factor to the severe dental erosion. She did not believe this. Consequently, several tests were done.
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Fig 1 ■ Severe erosion of premolars and first molar of maxillary left arch. Note loss of lingual cusps, exposure of dentin, and depressions (cupping] of buccal cusps.
Results of tests A call was placed to the hospital pharmacy to inquire about the pH of vitamin C tablets. The pharmacists did not know and recommended writing to the manufacturers. The patient submitted several tablets for testing. The pH levels were determined using a digital 110 ex panded pH meter with a standard glass elec trode (Corning). The pH of Aceribo-C wafers, 500 mg, used for three years, was 1.92. The pH of Acerola Chewable, 500-mg tablets, used for one month, was 1.63. (The manufacturer said that the pH of Acerola Chewable was 2.3.) The pH of a vitamin C chewable tablet (chosen at random), 300 mg from a nutrition center store, was 2.33. The pH of the investigator’s saliva collected while chewing a portion of an Aceribo-C wafer was 5.34 compared with a pH of 6.5 for stimulated (paraffin gum) saliva. The following experiment was performed on an extracted tooth. An Aceribo-C wafer was dissolved in 30 ml of distilled water. A maxil lary first premolar with no apparent caries or other dental defects was placed in the solution. The tooth was observed daily and measured buccolingually in the m id dle third at the height of contour with a vernier caliper. Re sults are indicated in Figure 3. From day 1 through day 3, the surface of the tooth felt rough. From day 4, when the measurement started to decrease, the surface was chalky and 254 ■ JADA, Vol. 107, August 1983
Fig 2 ■ Severe erosion of premolars and first molar of mandibular left arch. Note loss of occlusal cusps, cupping on occlusal surface, loss of buccal enamel, and restoration standing beyond tooth surface.
some could be scraped away with a fingernail. At day 8, the enamel was very chalky and some was missing at the cementoenamel junction. The open root apexes were soft. From day 8 until day 16, the same observations were made. After that, the process slowed. The surface was visibly smoother at day 18. By day 22, when the
chemical activity had apparently ceased, the enamel surface was white, smooth, and could not be easily scraped away. The pH of the solu tion at day 1 was 1.9 and at day 22 was 3.45. Follow-up of the patient has shown that she no longer chews the vitamin C tablets.
■£
— g,
Davs Fig 3 ■ Graph of results of experiment of tooth measured before and after placement in solution made with vitamin C tablet and distilled water.
CLINICAL REPORTS
Discussion It appears from this report that chewable /itamin C tablets can appreciably conxibute to the destruction of teeth. The pH if the vitamin C tablets is acidic, on par i/vith stomach acid. Although the pH level /aries from manufacturer to manufac:urer, the level of acidity is always high. Apparently the pH of the saliva can drop :o a level at which the tooth enamel can lose calcium by the formation of calcium :itrate complexes.6 This leaching of cal cium etches the surface,9,13,14 which is prone to attrition and abrasion, both of which can contribute to tooth surface loss.2,3,15 Many individuals are taking vitamin C in one form or another for “health” pur poses. There are reports that megadoses af vitamin C accelerate wound healing.16 3ne article on erosion recommends the use of tablets when vitamin C supple ments are considered.17 Another author questions the promotion of a vitamin C syrup supplement for children because it may not be cleared rapidly from the teeth.12 The recommended daily allow ance is 60 mg of ascorbic acid daily, which is the amount supplied in one small glass of juice. Supplemental vitamin tablets that are now chewable pose no problem relative to tooth destruction. However, the chew able supplements impose direct contact of ascorbic acid with teeth. If patients use excess amounts, as in this report, severe tooth surface loss can occur. If patients use lesser amounts, then it is presumed that the erosion can occur, but more slowly. A 1980 editorial18 warned that dental erosion can lead to disfigurement, pain, loss of function, and loss of teeth. The au thor stated that removal of the cause of erosion was a most important measure. The causes of dental erosion should be known so that the dentist may ask appro priate questions when looking for a cause for dental destruction and so that preven tive advice may be offered. The causes in dicated to date in the literature1,2,4,6,9-11,17 are listed by category in the Table. Of these, the dietary category is the most controllable. A detailed dietary history is necessary when dental erosion is noted. There are many variables concerning whether there will be damage to the teeth with acid products.10 In the present case, the time of contact, the area of contact, the buffering capacity of the saliva, and the use of other acids in the diet were vari ables. The time of contact of the acid with the teeth was extended because the tablets were multiple, large, hard, and chewable. The area of contact corresponded to the teeth used in chewing by this patient. The cusps of prem olars and m olars were
Table ■ Causes of dental erosion.__________ Dietary Fruits and food with citric acid: lemons, oranges, grapefruits, tomatoes, bananas Fruit juices Acid (carbonated) beverages soft drinks; nondietetic and dietetic Vinegar—pickled foods Candy—sour balls, mints Cordials Vitamin C Medicinal HC1 replacement Iron tonic Vitamin C Acid drops (tablets) Aspirin Regurgitational Anorexia nervosa Vomiting Stress—reflux phenomenon Occupational Industrial acids Idiopathic Acid saliva
primarily affected, whereas other teeth were apparently spared. This pattern of erosion differs from ero sions caused by acids in other forms: in dustrial acid exposure, the labial surfaces of the m axillary incisors are usually eroded; fruits and juices containing citric acid, the central and lateral incisors are more affected and the molars are least af fected; with regurgitation of stomach juices, as in anorexic patients,19 the labial surfaces are spared, whereas the lingual surfaces of the maxillary arch in particu lar are eroded and there is minimal loss of occlusal surfaces. In the present case, the pattern indicates that abrasion and attri tion were contributing factors. However, the demineralization by the acid in the tablets was essential. It caused a softening and loss of the superficial enamel that can be perceived by the consumer as rough ness with more friction.10 After the direct loss of superficial enamel by acid décalci fication , the rem aining layer of de mineralized enamel or dentin can be abraded.10 The buffering capacity of the saliva is a variable that differs from patient to pa tient and perhaps even in the sanie pa tient at different sites. In the present case, there was daily, direct contact of pure acid with the teeth. The saliva could act only as a limited buffer in the areas of di rect contact and was perhaps a better buf fer at a greater distance because there was no concentration of acid at those dis tances. The other variable in this case was the daily consumption of a 12-oz diet bever age. It has been reported that the daily in gestion of 12 oz or more of carbonated beverages or fruit juices can modify the enamel.4,11 The site and severity of tooth damage can vary and are not necessarily related to the amount consumed.11 How ever, drinking less than 12 oz over pro longed periods did not show significant
erosive changes.11 In another reported case of erosion caused by an unusual re ducing diet that used primarily 64 oz of soft drink and lemon concentrate,5 there was a pattern similar to the present case, but the essential factor for the erosion was thought to be the lemon concentrate, not the soft drink. Thus, the 12-oz beverage in this case may have been an additive fac tor, but it is unlikely that it is the primary factor causing the erosion. As thousands of people use vitamin C daily and as it is readily available in chewable form, consumers should be aware of the potential for damage to the teeth if tablets are chewed daily. Safe dos ages of vitamin C can be taken without chewing. Treatment for erosion may consist of the use of restorations, fluoride rinses, al kaline rinses, and mouthguards, along with the withdrawal of the cause if it is known. The best treatment is prevention. In the case of acid usage, a thorough his tory can disclose the presence of acid in the diet or environment. Removal of the acid used in excess can prevent further damage. Judicious use can prevent dam age altogether.
Summary A patient had severe dental erosion that was attributed primarily to the daily chewing of vitamin C tablets for three years. Tests were done to demonstrate the acidity of vitamin C tablets and the demineralization of enamel by a solution made with a tablet. The causes for dental erosion and the varying patterns of ero sion are reviewed. „. „ « ___________________________________ J S O A
The author thanks Rachel Hill for technical assistance and Mary Hayward for preparation of the manu script. Dr. Giunta is professor, department of oral pathol ogy, School of Dental Medicine, Tufts University, 1 Kneeland St, Boston 02111. Address requests for re prints to the author. 1. Stafne, E.C., and Lovestadt, S.A. Dissolution of tooth substance by lemon juice, acid beverages and acids from other sources. JADA 34(5):586-592,1947. 2. Pindborg, J.J. Pathology of the dental hard tis sues. Philadelphia, W. B. Saunders Co, 1970, pp 312321. 3. Levine, R.S. Fruit juice erosion—an increasing danger? JDent 2{2}:85-88,1973. 4. Eccles, J.D., and Jenkins, W.G. Dental erosion and diet. J Dent 2(4):153-159, 1974. 5. Mueninghoff, L.A., and Johnson, M.H. Erosion: a case caused by unusual diet. JADA 104(l):51-52, 1982. 6. Touyz, L.Z., and Glassman, R.M. Citrus, acid and teeth. JDent Assoc S Africa 36(3):195-201,1981. 7. Fuller, J.L., and Johnson, W.W. Citric acid con sumption and the human dentition. JADA 95(1):8084,1977. 8. McDonald, J.L., and Stookey, G.K. Laboratory studies concerning the effect of acid-containing bev erages on enamel dissolution and experimental den tal caries. J Dent Res 52:211-216,1973. 9. Jenkins, G.N. Enamel protective factors in food. J Dent Res 49:1318-1326,1970.
G iu n ta : E R O S IO N F R O M CH EW ABLE V IT A M IN C TABLETS ■ 255
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10. Davis, W.B., and Winter, P.J. The effect of abra sion on enamel and dentine after exposure to dietary acid. Br Dent J 148(11, 12):253-256, 1980. 11. Thomas, A.E. Further observations on the in fluence of citrus fruit juices on human teeth. NY State Dent J 23:424-430, 1957. 12. Woods, R.G. Vitamin C syrup (letter). Aust Dent J 26(5):336, 1981. 13. Sognnaes, R.F. Microradiographic observa
tions on demineralization gradients in the patho genesis of hard-tissue destruction. Arch Oral Biol 1:106-121, 1959. 14. Larsen, M.J. Dissolution of enamel. Scand J Dent Res 81:518-522, 1973. 15. Lewis, K.J., and Smith, B.G. The relationship of erosion and attrition in extensive tooth tissue loss. Br Dent J 135(9):400-404, 1973. 16. Ringsdorf, W.M., and Cheraskin, E. Vitamin C
and human wound healing. Oral Surg 53(3):231-236, 1982. 17. Smith, B.G. Dental erosion, attrition, and abra sion. Practitioner 214(1281):347-355, 1975. 18. Erosion of the teeth by acid (editorial). Lancet 2(8190):353, Aug 16, 1980. 19. Hurst, P.S.; Lacey, J.H.; and Crisp, A.H. Teeth, vomiting and diet: a study of the dental characteris tics of seventeen anorexia nervosa patients. Postgrad Med J 53(620):298-305, 1977.
Cervical erosion involving the lingual surface of a m andibular canine and adjacent premolars W illiam F. Stroner, D D S
A re v ie w o f the lite ra tu re and a case re p o rt are used to propose several hypotheses f o r c e rv ic a l erosion.
T
JL he cause of cervical dental erosion is obscure and, as varieties do exist, it may be a m ultifarious problem. The literature suggests such causes as: the m ucosal glands that lie in apposition to the af fected teeth produce and secrete acid; m uscular movement that supplies fric tion across submucous glands to stim u late secretion of the causative agent; fric tional ablation of hyperactive oral m u cosa that causes wear as w e ll as the perambulatory ruffling action of cellular activity; and acid secretions, inflam m a tory exudates, or acids produced by bacterial action on debris below the gin gival m argin that may bathe the cervical area of the teeth. A n unusual case of cervical erosion is reported in w hich the lingual surfaces of a m andibular canine and two premolars are involved. Lingual erosion occurring on m andibular premolars has not been pre viously reported. Buccal surfaces of other teeth are also affected and, as in all re ports, one side is more severely affected than the other. A variety of treatments are recommended that may benefit persons w ith cervical dental erosion. 256 ■ JADA, Vol. 107, August 1983
Review of literature In the majority of cervical dental erosion cases, the cause is unknow n. These le sions are sm ooth and hard, show no chalkiness, and occur on the labial and buccal surfaces of teeth. The lesions may also occur interproximally. The loss of tooth substance is usually indicated by a shallow , broad, h ig h ly polished, and scooped-out depression on the enamel surface adjacent to the cementoenamel junction. These lesions have a variety of sizes and shapes and usually involve sev eral teeth.1 Oral examinations show that cervical erosion is often left untreated. Dentists may advise their patients not to worry about the condition and usually make lit tle effort to correct it.2 The different types of dental erosion can be categorized as general or local.3 General erosion usually involves most of the teeth in the m o uth . A n acid that can be introduced by vom iting or regurgitation of the gastric contents is im plicated as the causative agent. M edication w ith hydro chloric acid may foment the décalcifica tion of teeth. In these instances, the lin gual surfaces are involved.3,4 Dental ero sion can be an occupational hazard for workers employed in an environment in w hich acid fumes are abundant. The pat tern of erosion arising from airborne fumes, mists, or particles seems to be fairly consistent in that the labial aspects of the incisors are attacked first.® Exces sive consum ption of citrus fruits and acidic soft drinks can also contribute to dental erosion.6,7 Cervical dental erosion, local erosion, is com m on but its cause is unknow n. M any researchers have im plicated citric a cid .3,711 Whereas some investigators shun the im plication that bacteria are the
cause, Sognnaes12 has demonstrated that there are microorganisms on the surface of these lesions that cause what he terms “ idiopathic dental erosion.” Stafne and Lovestedt7 observed injury to tooth structure clinically and related the rise to the increased availability of cit rus fruits. They observed 50 subjects from North and South America. Thirty-nine were female and 11 male, and all were using lemon juice in water as a therapeu tic measure. There was no uniform ity in the decalcified areas of the teeth, but all the subjects had erosion. Stafne and Lovestedt7 speculated that the varience m ight be a result of the buffering capacity of saliva. McClure8 studied the effect of acid so lutions on the teeth of rats. He separated litte rm a te w e a n lin g rats in to three groups, each group drinking one of the following: distilled water, HC1 solution (pH 1.5, 0.16%), or lactic acid solution (pH 2.4, 0.5%). A ll anim als were provided w ith the same solid diet and fluids were allowed ad libitum . M andibular molars were more severely affected than m axil lary molars, and the severest dissolution occurred on the lingual surface of m an dibular molars. The crowns of some m an dibular molars were nearly destroyed. The HC1 solution that had the lowest pH caused the most destruction. The fact that some of the anim als’ teeth were injured more than others was attributed to the d if ferences in drinking habits and possibly to in d iv idu al susceptibility. The pronounced destruction of dentin and enamel of the molars of rats caused by diluted acid solutions and certain acid beverages that were consumed regularly in place of drinking water demonstrated that hard tooth structure is affected by acid fluids passing through the oral cav ity.
nated Kaposi’s sarcoma in homosexual males. Ann Intern Med 96(6):693-700, 1982. 17. Friedman-Kien, A.E. Disseminated Kaposi’s sarcoma in young homosexual men. J Am Acad Der matol 5(4):468-471, 1981. 18. Thomsen, H.K.; Jacobsen, M.; MalchowMoller, A. Kaposi’s sarcoma among homosexual men in Europe. Lancet 2:688, 1981. 19. Hymes, K.B., and others. Kaposi’s sarcoma in homosexual men: a report of eight cases. Lancet 2:598-600, 1981. 20. Gottlieb, G.J., and others. A preliminary com munication on extensively disseminated Kaposi’s sarcoma in young homosexual men. Am J Dermatopathol 3(2):111-114, 1981. 21. Masur, H., and others. An outbreak of com munity-acquired Pneumocystis carinii pneumonia: initial manifestation of cellular immune dysfunction. N Engl J Med 305(24):1431-1438, 1981. 22. Siegal, F.P., and others. Severe acquired immunodeficiency in male homosexuals, manifested by chronic perianal ulcerative herpes simplex le sions. N Engl J Med 305(24):1439-1444, 1981. 23. Sterak, D. Opportunistic infections and Kaposi’s sarcoma in homosexual men. N Engl J Med 305(24):1465-1467, 1981. 24. Friedman-Kien, A., and others. Kaposi’s sar coma and Pneumocystis pneumonia among homo
REPORTS
sexual men: New York City and California. MMWR 30(25):305-308, 1981. 25. Kornfeld, H., and others. T-lymphocyte sub populations in homosexual men. N Engl J Med 307(12):729-931, 1982. 26. Lozada, F.; Silverman, S., Jr.; and Conant, M. New outbreak of oral tumors, malignancies and infec tious disease strikes young male homosexuals. Calif Dent Assoc J 10(5):39-42, 1982. 27. Alper, R.A., and Wiggins, H.E. Hemorrhagic palatal lesion. J Oral Pathol 4(4):222-228, 1975. 28. Guarda, L.G., and others. Factor VIII in Kaposi’s sarcoma. Am J Clin Pathol 76(2):197-200, 1981. 29. Haverkos, H.W., and Curran, J.W. The current outbreak of Kaposi’s sarcoma and opportunistic in fections. CA 32(6):330-339, 1982. 30. Vieira, J., and others. Acquired immune defi ciency in Haitians. Opportunistic infections in previ ously healthy Haitian immigrants. N Engl J Med 308(3):125-129, 1983. 31. Centers for Disease Control. Hepatitis B virus vaccine safety: report of an inter-agency group. MMWR 31(34):465-467, 1982. 32. Farman, A.G., and Uys, P.B. Oral Kaposi’s sar coma. Oral Surg 39(2):288-296, 1975.
Dental erosion resulting from chewable vitam in C tablets John L. Giunta, DMD, MS
The use o f chew able vita m in C is shown to cause the p H o f sa liva to drop to a le v e l at w hich tooth enam el can lose calcium b y the fo rm a tio n o f calcium citra te complexes. A case is reported.
V
itamin C, L-ascorbic acid, which is used in excess in the form of fruit juices, raw fruits, and even cordials, is known to cause or be directly associated with human dental erosion.111 A correlation between supplemental vitamin C and dental erosion has also been suggested for vitamin C syrup,12 but not for tablets. With the recent popularity of the use of supplem ental vitam in C, prescribed either professionally or self-prescribed, the use of vitamin C in tablet form has in creased. Distributors are claiming that the tablets are delicious, fruit-flavored, and
chewable. However, there is no warning that chewing vitamin C tablets may be detrimental to teeth. What follows is a case report and discussion on the effects of chewable vitamin C on teeth and a plea that dental erosion of this type is prevent able.
Report of case A 30-year-old female had requested a second opinion about whether her teeth were eroded and what might be the probable cause. Her dentist had informed her that she had severe dental erosion that required restoration by full crowns on at least 12 teeth. She wanted to know the cause so that the process might be halted before proceeding with restorative den tistry. Currently, her teeth were painful to brush and she had been told to use a desensitiz ing toothpaste. Her medical history showed an eye muscle operation at age 5; at 25, infectious mononucleosis and an epigastric hernia; and previous allergies to grass and pollen. She took medicine for iron-deficiency anemia and for menstrual pain. When questioned about pills, she admitted taking vitamin supplements, in cluding chewable vitamin C tablets. The exam ination showed the patient to be healthy. In traoral examination showed that there were several posterior teeth with deficient tooth structure. In the maxilla, the occlusal surface and lin gual cusps were missing on the premolars and on the first molars, where the mesiolingual
cusp was the most affected. The buccal sur faces were normal. The second molar and the other teeth appeared unaffected. In the mandi ble, the occlusal surfaces and the buccal and lingual cusps on the premolars and the first molars were missing; the buccal enamel was more affected than the lingual. There was cup ping on the occlusal surfaces. The second molar and the other teeth appeared unaffected. The exposed dentin was deep yellow, smooth, and shiny. The left side of the mouth was more involved with the process than the right side
(Fig 1. 2). Oral hygiene was good and no caries was noted. R adiographs that the patient had brought were inconclusive because of their poor quality. No further radiographs were taken. The diagnosis was severe dental ero sion. Further questioning concerned the patient’s diet with specific reference to the use of citrus or acid-containing beverages. She drank one 12-oz can of a diet beverage each day, and had chewed three tablets of megadosage vitamin C (Aceribo-C) each day for the past three years. One month before her visit, she had changed brands (Acerola Chewable), but was still taking v ita m in C. She de n ie d reg urg ita tio n of stomach contents. There was no occupational exposure to acid. The patient was advised that the daily expo sure to multiple chewable vitamin C tablets was most likely a major contributing factor to the severe dental erosion. She did not believe this. Consequently, several tests were done.
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Fig 1 ■ Severe erosion of premolars and first molar of maxillary left arch. Note loss of lingual cusps, exposure of dentin, and depressions (cupping] of buccal cusps.
Results of tests A call was placed to the hospital pharmacy to inquire about the pH of vitamin C tablets. The pharmacists did not know and recommended writing to the manufacturers. The patient submitted several tablets for testing. The pH levels were determined using a digital 110 ex panded pH meter with a standard glass elec trode (Corning). The pH of Aceribo-C wafers, 500 mg, used for three years, was 1.92. The pH of Acerola Chewable, 500-mg tablets, used for one month, was 1.63. (The manufacturer said that the pH of Acerola Chewable was 2.3.) The pH of a vitamin C chewable tablet (chosen at random), 300 mg from a nutrition center store, was 2.33. The pH of the investigator’s saliva collected while chewing a portion of an Aceribo-C wafer was 5.34 compared with a pH of 6.5 for stimulated (paraffin gum) saliva. The following experiment was performed on an extracted tooth. An Aceribo-C wafer was dissolved in 30 ml of distilled water. A maxil lary first premolar with no apparent caries or other dental defects was placed in the solution. The tooth was observed daily and measured buccolingually in the m id dle third at the height of contour with a vernier caliper. Re sults are indicated in Figure 3. From day 1 through day 3, the surface of the tooth felt rough. From day 4, when the measurement started to decrease, the surface was chalky and 254 ■ JADA, Vol. 107, August 1983
Fig 2 ■ Severe erosion of premolars and first molar of mandibular left arch. Note loss of occlusal cusps, cupping on occlusal surface, loss of buccal enamel, and restoration standing beyond tooth surface.
some could be scraped away with a fingernail. At day 8, the enamel was very chalky and some was missing at the cementoenamel junction. The open root apexes were soft. From day 8 until day 16, the same observations were made. After that, the process slowed. The surface was visibly smoother at day 18. By day 22, when the
chemical activity had apparently ceased, the enamel surface was white, smooth, and could not be easily scraped away. The pH of the solu tion at day 1 was 1.9 and at day 22 was 3.45. Follow-up of the patient has shown that she no longer chews the vitamin C tablets.
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Davs Fig 3 ■ Graph of results of experiment of tooth measured before and after placement in solution made with vitamin C tablet and distilled water.
CLINICAL REPORTS
Discussion It appears from this report that chewable /itamin C tablets can appreciably conxibute to the destruction of teeth. The pH if the vitamin C tablets is acidic, on par i/vith stomach acid. Although the pH level /aries from manufacturer to manufac:urer, the level of acidity is always high. Apparently the pH of the saliva can drop :o a level at which the tooth enamel can lose calcium by the formation of calcium :itrate complexes.6 This leaching of cal cium etches the surface,9,13,14 which is prone to attrition and abrasion, both of which can contribute to tooth surface loss.2,3,15 Many individuals are taking vitamin C in one form or another for “health” pur poses. There are reports that megadoses af vitamin C accelerate wound healing.16 3ne article on erosion recommends the use of tablets when vitamin C supple ments are considered.17 Another author questions the promotion of a vitamin C syrup supplement for children because it may not be cleared rapidly from the teeth.12 The recommended daily allow ance is 60 mg of ascorbic acid daily, which is the amount supplied in one small glass of juice. Supplemental vitamin tablets that are now chewable pose no problem relative to tooth destruction. However, the chew able supplements impose direct contact of ascorbic acid with teeth. If patients use excess amounts, as in this report, severe tooth surface loss can occur. If patients use lesser amounts, then it is presumed that the erosion can occur, but more slowly. A 1980 editorial18 warned that dental erosion can lead to disfigurement, pain, loss of function, and loss of teeth. The au thor stated that removal of the cause of erosion was a most important measure. The causes of dental erosion should be known so that the dentist may ask appro priate questions when looking for a cause for dental destruction and so that preven tive advice may be offered. The causes in dicated to date in the literature1,2,4,6,9-11,17 are listed by category in the Table. Of these, the dietary category is the most controllable. A detailed dietary history is necessary when dental erosion is noted. There are many variables concerning whether there will be damage to the teeth with acid products.10 In the present case, the time of contact, the area of contact, the buffering capacity of the saliva, and the use of other acids in the diet were vari ables. The time of contact of the acid with the teeth was extended because the tablets were multiple, large, hard, and chewable. The area of contact corresponded to the teeth used in chewing by this patient. The cusps of prem olars and m olars were
Table ■ Causes of dental erosion.__________ Dietary Fruits and food with citric acid: lemons, oranges, grapefruits, tomatoes, bananas Fruit juices Acid (carbonated) beverages soft drinks; nondietetic and dietetic Vinegar—pickled foods Candy—sour balls, mints Cordials Vitamin C Medicinal HC1 replacement Iron tonic Vitamin C Acid drops (tablets) Aspirin Regurgitational Anorexia nervosa Vomiting Stress—reflux phenomenon Occupational Industrial acids Idiopathic Acid saliva
primarily affected, whereas other teeth were apparently spared. This pattern of erosion differs from ero sions caused by acids in other forms: in dustrial acid exposure, the labial surfaces of the m axillary incisors are usually eroded; fruits and juices containing citric acid, the central and lateral incisors are more affected and the molars are least af fected; with regurgitation of stomach juices, as in anorexic patients,19 the labial surfaces are spared, whereas the lingual surfaces of the maxillary arch in particu lar are eroded and there is minimal loss of occlusal surfaces. In the present case, the pattern indicates that abrasion and attri tion were contributing factors. However, the demineralization by the acid in the tablets was essential. It caused a softening and loss of the superficial enamel that can be perceived by the consumer as rough ness with more friction.10 After the direct loss of superficial enamel by acid décalci fication , the rem aining layer of de mineralized enamel or dentin can be abraded.10 The buffering capacity of the saliva is a variable that differs from patient to pa tient and perhaps even in the sanie pa tient at different sites. In the present case, there was daily, direct contact of pure acid with the teeth. The saliva could act only as a limited buffer in the areas of di rect contact and was perhaps a better buf fer at a greater distance because there was no concentration of acid at those dis tances. The other variable in this case was the daily consumption of a 12-oz diet bever age. It has been reported that the daily in gestion of 12 oz or more of carbonated beverages or fruit juices can modify the enamel.4,11 The site and severity of tooth damage can vary and are not necessarily related to the amount consumed.11 How ever, drinking less than 12 oz over pro longed periods did not show significant
erosive changes.11 In another reported case of erosion caused by an unusual re ducing diet that used primarily 64 oz of soft drink and lemon concentrate,5 there was a pattern similar to the present case, but the essential factor for the erosion was thought to be the lemon concentrate, not the soft drink. Thus, the 12-oz beverage in this case may have been an additive fac tor, but it is unlikely that it is the primary factor causing the erosion. As thousands of people use vitamin C daily and as it is readily available in chewable form, consumers should be aware of the potential for damage to the teeth if tablets are chewed daily. Safe dos ages of vitamin C can be taken without chewing. Treatment for erosion may consist of the use of restorations, fluoride rinses, al kaline rinses, and mouthguards, along with the withdrawal of the cause if it is known. The best treatment is prevention. In the case of acid usage, a thorough his tory can disclose the presence of acid in the diet or environment. Removal of the acid used in excess can prevent further damage. Judicious use can prevent dam age altogether.
Summary A patient had severe dental erosion that was attributed primarily to the daily chewing of vitamin C tablets for three years. Tests were done to demonstrate the acidity of vitamin C tablets and the demineralization of enamel by a solution made with a tablet. The causes for dental erosion and the varying patterns of ero sion are reviewed. „. „ « ___________________________________ J S O A
The author thanks Rachel Hill for technical assistance and Mary Hayward for preparation of the manu script. Dr. Giunta is professor, department of oral pathol ogy, School of Dental Medicine, Tufts University, 1 Kneeland St, Boston 02111. Address requests for re prints to the author. 1. Stafne, E.C., and Lovestadt, S.A. Dissolution of tooth substance by lemon juice, acid beverages and acids from other sources. JADA 34(5):586-592,1947. 2. Pindborg, J.J. Pathology of the dental hard tis sues. Philadelphia, W. B. Saunders Co, 1970, pp 312321. 3. Levine, R.S. Fruit juice erosion—an increasing danger? JDent 2{2}:85-88,1973. 4. Eccles, J.D., and Jenkins, W.G. Dental erosion and diet. J Dent 2(4):153-159, 1974. 5. Mueninghoff, L.A., and Johnson, M.H. Erosion: a case caused by unusual diet. JADA 104(l):51-52, 1982. 6. Touyz, L.Z., and Glassman, R.M. Citrus, acid and teeth. JDent Assoc S Africa 36(3):195-201,1981. 7. Fuller, J.L., and Johnson, W.W. Citric acid con sumption and the human dentition. JADA 95(1):8084,1977. 8. McDonald, J.L., and Stookey, G.K. Laboratory studies concerning the effect of acid-containing bev erages on enamel dissolution and experimental den tal caries. J Dent Res 52:211-216,1973. 9. Jenkins, G.N. Enamel protective factors in food. J Dent Res 49:1318-1326,1970.
G iu n ta : E R O S IO N F R O M CH EW ABLE V IT A M IN C TABLETS ■ 255
C L IN IC A L
REPORTS
10. Davis, W.B., and Winter, P.J. The effect of abra sion on enamel and dentine after exposure to dietary acid. Br Dent J 148(11, 12):253-256, 1980. 11. Thomas, A.E. Further observations on the in fluence of citrus fruit juices on human teeth. NY State Dent J 23:424-430, 1957. 12. Woods, R.G. Vitamin C syrup (letter). Aust Dent J 26(5):336, 1981. 13. Sognnaes, R.F. Microradiographic observa
tions on demineralization gradients in the patho genesis of hard-tissue destruction. Arch Oral Biol 1:106-121, 1959. 14. Larsen, M.J. Dissolution of enamel. Scand J Dent Res 81:518-522, 1973. 15. Lewis, K.J., and Smith, B.G. The relationship of erosion and attrition in extensive tooth tissue loss. Br Dent J 135(9):400-404, 1973. 16. Ringsdorf, W.M., and Cheraskin, E. Vitamin C
and human wound healing. Oral Surg 53(3):231-236, 1982. 17. Smith, B.G. Dental erosion, attrition, and abra sion. Practitioner 214(1281):347-355, 1975. 18. Erosion of the teeth by acid (editorial). Lancet 2(8190):353, Aug 16, 1980. 19. Hurst, P.S.; Lacey, J.H.; and Crisp, A.H. Teeth, vomiting and diet: a study of the dental characteris tics of seventeen anorexia nervosa patients. Postgrad Med J 53(620):298-305, 1977.
Cervical erosion involving the lingual surface of a m andibular canine and adjacent premolars W illiam F. Stroner, D D S
A re v ie w o f the lite ra tu re and a case re p o rt are used to propose several hypotheses f o r c e rv ic a l erosion.
T
JL he cause of cervical dental erosion is obscure and, as varieties do exist, it may be a m ultifarious problem. The literature suggests such causes as: the m ucosal glands that lie in apposition to the af fected teeth produce and secrete acid; m uscular movement that supplies fric tion across submucous glands to stim u late secretion of the causative agent; fric tional ablation of hyperactive oral m u cosa that causes wear as w e ll as the perambulatory ruffling action of cellular activity; and acid secretions, inflam m a tory exudates, or acids produced by bacterial action on debris below the gin gival m argin that may bathe the cervical area of the teeth. A n unusual case of cervical erosion is reported in w hich the lingual surfaces of a m andibular canine and two premolars are involved. Lingual erosion occurring on m andibular premolars has not been pre viously reported. Buccal surfaces of other teeth are also affected and, as in all re ports, one side is more severely affected than the other. A variety of treatments are recommended that may benefit persons w ith cervical dental erosion. 256 ■ JADA, Vol. 107, August 1983
Review of literature In the majority of cervical dental erosion cases, the cause is unknow n. These le sions are sm ooth and hard, show no chalkiness, and occur on the labial and buccal surfaces of teeth. The lesions may also occur interproximally. The loss of tooth substance is usually indicated by a shallow , broad, h ig h ly polished, and scooped-out depression on the enamel surface adjacent to the cementoenamel junction. These lesions have a variety of sizes and shapes and usually involve sev eral teeth.1 Oral examinations show that cervical erosion is often left untreated. Dentists may advise their patients not to worry about the condition and usually make lit tle effort to correct it.2 The different types of dental erosion can be categorized as general or local.3 General erosion usually involves most of the teeth in the m o uth . A n acid that can be introduced by vom iting or regurgitation of the gastric contents is im plicated as the causative agent. M edication w ith hydro chloric acid may foment the décalcifica tion of teeth. In these instances, the lin gual surfaces are involved.3,4 Dental ero sion can be an occupational hazard for workers employed in an environment in w hich acid fumes are abundant. The pat tern of erosion arising from airborne fumes, mists, or particles seems to be fairly consistent in that the labial aspects of the incisors are attacked first.® Exces sive consum ption of citrus fruits and acidic soft drinks can also contribute to dental erosion.6,7 Cervical dental erosion, local erosion, is com m on but its cause is unknow n. M any researchers have im plicated citric a cid .3,711 Whereas some investigators shun the im plication that bacteria are the
cause, Sognnaes12 has demonstrated that there are microorganisms on the surface of these lesions that cause what he terms “ idiopathic dental erosion.” Stafne and Lovestedt7 observed injury to tooth structure clinically and related the rise to the increased availability of cit rus fruits. They observed 50 subjects from North and South America. Thirty-nine were female and 11 male, and all were using lemon juice in water as a therapeu tic measure. There was no uniform ity in the decalcified areas of the teeth, but all the subjects had erosion. Stafne and Lovestedt7 speculated that the varience m ight be a result of the buffering capacity of saliva. McClure8 studied the effect of acid so lutions on the teeth of rats. He separated litte rm a te w e a n lin g rats in to three groups, each group drinking one of the following: distilled water, HC1 solution (pH 1.5, 0.16%), or lactic acid solution (pH 2.4, 0.5%). A ll anim als were provided w ith the same solid diet and fluids were allowed ad libitum . M andibular molars were more severely affected than m axil lary molars, and the severest dissolution occurred on the lingual surface of m an dibular molars. The crowns of some m an dibular molars were nearly destroyed. The HC1 solution that had the lowest pH caused the most destruction. The fact that some of the anim als’ teeth were injured more than others was attributed to the d if ferences in drinking habits and possibly to in d iv idu al susceptibility. The pronounced destruction of dentin and enamel of the molars of rats caused by diluted acid solutions and certain acid beverages that were consumed regularly in place of drinking water demonstrated that hard tooth structure is affected by acid fluids passing through the oral cav ity.