1. Schenkel, Sara BS, RN
  2. Mulvaney-Roth, Patricia MS, RN, PMHCNS-BC, ACNS
  3. Hanna, Debra R. PhD, RN, ACNS-BC


Abstract: Learn when and how to educate patients who are at high risk for tooth damage, especially those experiencing high-frequency or chronic vomiting.


Article Content

Dental erosion, in which acid wears away tooth enamel, is a slowly evolving condition with serious long-term outcomes. Tooth sensitivity is the first sign that dental erosion is underway. As dental erosion evolves, teeth become weak, discolored, and painful. Biting into and chewing meats, dense breads, or hard fruits such as apples becomes difficult. If dental erosion continues unchecked, it can cause lifelong problems. Untreated dental erosion can become so severe that teeth will break. Once they're made aware of this problem, high-risk patients can prevent or stop further dental erosion.

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Currently, knowledge about dental erosion is nearly exclusively held by dentists and dental hygienists, so they're the providers who most often teach high-risk patients. Yet, patients who are at risk for developing dental erosion usually see physicians and nurses for different conditions that lead to dental erosion before they visit their dentists. Neither physicians nor nurses are routinely taught to assess or intervene to prevent dental erosion, and nurses typically aren't taught how to educate patients to prevent early dental erosion from progressing. Thus, at-risk patients in the healthcare setting, such as those with high-frequency or chronic vomiting, aren't guided on how to protect their teeth from dental erosion. The purpose of this article is to address this knowledge gap for nurses at all levels of practice.


Who's at risk?

High-frequency or chronic vomiting is a symptom that increased the risk of dental erosion for many patients. Dental erosion has been most frequently studied in patients with gastroesophageal reflux disease (GERD), bulimia, and hyperemesis gravidarum. Two other patient groups with high-frequency or chronic vomiting have been identified, but not well studied: patients with cancer who are receiving emesis-inducing chemotherapy treatment and patients using cannabinoid products to reduce persistent nausea and vomiting who experience the paradoxical response known as cannabinoid hyperemesis syndrome. The latter patient group is likely to grow given recent changes in legal availability of cannabinoid products.


There are two patient groups without high-frequency or chronic vomiting who are also at risk for dental erosion: patients with limited upper extremity mobility and dexterity, such as those who've experienced a stroke or are diagnosed with Parkinson disease or rheumatoid arthritis, and patients who take medications that cause dry mouth.


How it happens

Two types of factors lead to dental erosion: endogenous factors and exogenous factors. Endogenous factors are internal physiologic factors that are usually involuntary. People have little control over endogenous factors. Exogenous factors are external elements introduced into the body that can promote frequent vomiting or softening of tooth enamel. People have more control over exogenous factors.


Endogenous factors

Endogenous factors that contribute to dental erosion include physiologic conditions with repeated vomiting where gastric acids regularly contact teeth. Excessive vomiting and gastric reflux are two ways that gastric acids touch teeth regularly. Single, isolated episodes of vomiting or heartburn aren't sufficient to cause dental erosion; it's the daily, repeated nature of vomiting or gastric reflux that disrupts and erodes protective tooth enamel.1


GERD is an endogenous factor that can cause dental erosion. When people lie flat during sleep, gastric acids can flow into their oral cavities. Gastric acids can have a pH as low as 2.0. The regular, nightly exposure of tooth enamel to gastric acids leads to gradual degradation of the patient's teeth (see A closer look at dental erosion). Patients may not know that dental erosion is occurring along with their noted GERD symptoms, such as belching, heartburn, chronic cough, regurgitation, and chronic hoarseness. Some patients become aware of their dental erosion only through a routine dental visit.2 This timing of events represents a loss of opportunity to prevent dental erosion. Patients with GERD are routinely assessed and managed first by physicians and nurses. This is when patients enter a "potential zone of contact" where they can be helped through education provided by physicians and nurses to prevent dental erosion.


Patients with bulimia purposely induce vomiting after eating to maintain a low body weight. During self-induced vomiting, gastric acids wash over tooth surfaces, softening tooth enamel on contact. Proteolytic enzymes in gastric acids weaken healthy salivary pellicles, demineralize enamel and dentin, and contribute to dental erosion.3 To hide the odor of self-induced vomiting, patients may brush their teeth immediately after vomiting while tooth enamel is still soft. Once oral pH decreases after exposure to acids, tooth enamel becomes soft and vulnerable for approximately 60 minutes.4 Brushing during this time can damage and remove tooth enamel.


Hyperemesis gravidarum, or excessive vomiting during pregnancy, is another endogenous factor that can lead to dental erosion due to intractable vomiting, dry heaves, and/or unrelenting nausea. In severe cases of hyperemesis gravidarum, patients are at increased risk for extensive tooth damage.5 The HyperEmesis Level Prediction, or HELP, score can be used to monitor symptom severity and treatment response in patients who experience intense vomiting (see The HELP score).5

Figure. The HELP sco... - Click to enlarge in new windowFigure. The HELP score

Chemotherapeutic agents, such as 5-FU, cisplatin, carboplatin, oxaliplatin, and doxorubicin, frequently induce nausea and vomiting. Toxins in these drugs cause apoptosis, or cell-death-by-rupture, of cancer cells; however, the caustic nature of chemotherapy also taxes healthy areas of the body. The degree of nausea and vomiting is more intense when chemotherapies target brain tissue, liver tissue, or the gastrointestinal tract. There are five patterns of vomiting associated with patients who receive chemotherapy (see Five patterns of chemotherapy-induced nausea and vomiting).6


Cannabinoid hyperemesis syndrome is severe cyclic vomiting, often with abdominal pain, that occurs after overuse of cannabis.7 The irony of cannabinoid hyperemesis syndrome is that it can occur for people who use cannabinoid products to control nausea and vomiting. Although discovered in 2004, cannabinoid hyperemesis syndrome is still largely unknown. States with legal cannabis use are more likely to see cases of cannabinoid hyperemesis syndrome. Because cannabinoid hyperemesis syndrome has a symptom profile like hyperemesis gravidarum, it's important for clinicians to differentiate between the two conditions in chronic cannabis users who are also pregnant. Ask when vomiting began to determine if it predates the pregnancy. If so, ask if there's cannabis use. The best treatment for cannabinoid hyperemesis syndrome is cessation of cannabis use.

Five patterns of che... - Click to enlarge in new windowFive patterns of chemotherapy-induced nausea and vomiting
Commonly prescribed ... - Click to enlarge in new windowCommonly prescribed medications causing dry mouth

Another endogenous factor leading to dental erosion is dry mouth or xerostomia, which can be caused by certain medications, dehydration from eating disorders, or after treatments for head and neck cancers (see Commonly prescribed medications causing dry mouth). A healthy salivary level keeps teeth strong by diluting, clearing, and buffering acids that contact them, whereas a scant quantity of neutralizing saliva permits the oral cavity pH to become more acidic.8,9 Because some prescribed medications can cause dry mouth, patients must be educated about how to manage dental hygiene.


Exogenous factors

Exogenous factors are external sources of acid that lead to dental erosion. Most patients are unaware that their personal eating or drinking habits can cause tooth damage. For example, cola sodas have a pH of 2.3 and lemon juice has a pH of 2.0 (see pH of common drinks). In fact, any food or beverage with a pH lower than 5.5 that contacts teeth can soften the hard outer layer of tooth enamel. Foods and drinks with a low pH and a high buffering capacity are more resistant to saliva's neutralizing effects on oral pH levels. This capacity to resist saliva's neutralizing effect sets up a perfect environment for dental erosion to begin.2


The time of day when acidic beverages are consumed is also important to note. Because saliva production is reduced at night during sleep, consuming large amounts of acidic beverages in the late evening will promote dental erosion during sleep hours. Take a thorough case history and assess for patterns of ingestion of acidic beverages, including frequency and time of day consumed. In contrast to the effect of consuming acidic beverages in the late evening, drinking milk or water during this time is more likely to protect teeth.10


People use oral care products, such as toothpaste and mouthwash, to keep their mouths clean and breath fresh. Oral care products for the prevention of cavities are regulated by the US FDA as over-the-counter (OTC) drugs. Although teeth-whitening procedures by dentists and dental hygienists are FDA-approved, OTC teeth-whitening products are categorized as cosmetics and therefore not under the FDA's jurisdiction. Teeth-whitening products, with and without hydrogen peroxide, can permanently alter enamel. The American Dental Association petitioned the FDA in 2009 to regulate OTC teeth-whitening products, claiming that teeth-whitening products can damage the teeth and oral soft tissue. In fact, the pH of some teeth-whitening agents is so low that it causes changes in the mineral content of tooth enamel.11 This contributes to the formation of shallow tooth depressions, increases enamel porosity, and promotes slight erosion. Because OTC teeth-whitening products remain unregulated, ask patients if they regularly use them. If the answer is "yes," follow up with an assessment for possible dental erosion and provide proper patient education.

pH of common drinks... - Click to enlarge in new windowpH of common drinks

Nursing interventions

Whether dental erosion develops from endogenous or exogenous factors, nurses can identify at-risk patients and provide patient-specific teaching on self-care strategies to preserve dental health. Nurses who encounter patients later in the process of dental erosion can advocate for referral to a dentist for specialized dental care.


Avoiding "the vulnerable hour"

Most people aren't aware of the hour of vulnerability after vomiting when highly acidic gastric acids contact teeth. The danger during the vulnerable hour is that the tooth-brushing motion, especially with hard bristle toothbrushes, can brush away tooth enamel, which stays soft and vulnerable as long as the oral pH stays low. The best cleaning strategy is to rinse the oral cavity with a warm saltwater mixture or with warm tap water to neutralize the acidic pH. Once the oral pH is neutralized, patients should wait 60 minutes for tooth enamel to harden again before brushing their teeth. An ultrasoft or supersoft toothbrush is recommended because gentle cleaning will preserve enamel and avoid further dental erosion.12


For patients with frequent vomiting, a good saltwater rinse recipe is 1 teaspoon of baking soda, 1 teaspoon of table salt, and 1 quart of warm water mixed well. The solution should be warm, not hot or cold, to prevent patient discomfort. If the solution is too hot, it could burn the oral cavity and cause pain. If the solution is too cold, it could increase pain from tooth sensitivity. For patients with tooth sensitivity, room temperature fluids (about 72[degrees] F [22[degrees] C]) are still too cold. The ideal temperature is around 98[degrees] F (36.6[degrees] C). This mixture can be kept warm in a thermos for about 12 hours so easy rinsing after each episode of vomiting will preserve tooth enamel, cleanse the oral cavity, and neutralize oral pH.


For patients with a temporary but persistent case of frequent vomiting, such as with those experiencing hyperemesis gravidarum or undergoing emesis-inducing chemotherapy, saltwater rinses are a valuable self-care strategy to preserve teeth. Saltwater rinsing avoids tooth brushing during the vulnerable period while cleansing and neutralizing the oral cavity. When it's safe to brush teeth again, starting on the back teeth first delays toothpaste from coming into contact with taste buds, which can trigger vomiting.


Nurses who provide patient education about how to manage the vulnerable hour after vomiting or consuming acidic foods and beverages can actively reduce patients' progression toward severe dental erosion and tooth fractures. Nurses can recommend that patients with high-frequency or chronic vomiting have regularly scheduled dental checkups for consistency of dental care. Oncology nurses can reduce the frequency and intensity of vomiting after chemotherapy or radiation by administering I.V. or oral antiemetics prophylactically before patients receive treatments known to trigger vomiting. Oral as-needed antiemetic medications can also be provided for home use while ambulatory chemotherapy and radiation treatments are underway. Nurses and patients can work together to find a medication and self-care regimen that prevents the extreme effects of dental erosion.


Fluoride treatments and rinses

Fluoride helps prevent acid from breaking down tooth enamel by maintaining an alkali buffer.13 Fluoride can be administered as a gel, oral rinse, or tablet. Multiple researchers have recommended that post acid exposure, fluoride rinses can help neutralize acid and prevent dental erosion.1,9,13,14


Diet changes

Avoiding acidic foods and drinks, especially soft drinks, is a lifestyle change patients can make to stop dental erosion from progressing. Decreasing alcohol consumption and chewing gum after meals will also help. Chewing gum can increase salivary flow rate and frequency, which promotes saliva's protective effect against dental erosion. In patients with GERD, avoiding foods and beverages that trigger symptoms and remaining upright after eating can prevent acid from reaching the mouth. Drinking milk after the final meal of the day will help neutralize gastric acids. Teach patients that consuming milk or low-sugar dairy products after the final meal protects teeth against dental erosion.


Nurses who assess patients' dietary habits can identify foods and beverages that will increase or decrease the likelihood of dental erosion. Nurses can advocate for patients to receive a consultation with a nutritionist to find culturally pleasing alternatives as needed. Nurses who assess patients' knowledge about proper dental hygiene and nutrition can tailor patient teaching to close individual patient knowledge gaps.


Qualities of upper extremity movements

Patients who've experienced a stroke that affected their dominant hand may have a weakness, which makes brushing difficult, or a paralysis, which involves patients learning how to brush their teeth with their nondominant hand. Patients with Parkinson disease who have an intention tremor or who can't control their upper extremity movements fluidly will also have difficulty executing movements for proper dental hygiene. And patients with rheumatoid arthritis and hand/finger deformities may not be able to hold a toothbrush easily.


Nurses know that a patient's dental hygiene partly depends on their ability to perform self-care or get assistance when they're unable to care for themselves. Patients need adequate motor skills to brush their teeth on all dental surfaces for at least 30 seconds/surface. Upper extremity strength, dexterity, and coordination are needed for proper dental hygiene, along with the kinesthetic ability of knowing where one's hand is in space and smoothness of movements. Nurses' astute assessment of the qualities of upper extremity movements can inform how to educate patients to best engage in dental hygiene self-care.


Education is key

Although the discipline of nursing hardly appears in the literature about dental erosion, nurses are highly engaged with many patients at risk for this functional problem. Nurses working in a variety of healthcare settings can identify risk factors, provide basic patient education about proper dental hygiene self-care to stop or slow further dental erosion, and advocate for follow-up with dental and nutrition professionals. Whether in outpatient or inpatient settings, nurses can assess patients' motor skills, dietary habits, and health history, using their holistic assessment to address individual educational needs.


A closer look at dental erosion

This extensive enamel erosion was seen in an individual with chronic severe GERD of more than 10 years' duration.


Source: DeLong L, Burkhart NW. General and Oral Pathology for the Dental Hygienist. 3rd ed. Burlington, MA: Jones & Bartlett Learning; 2018.

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Consider this

Case study #1

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Brianna, 35, wants to get pregnant but has experienced amenorrhea for the past 6 months. The nurse notices Brianna's body mass index is 17.25, possibly indicating an eating disorder. During the history and physical exam, Brianna mentions sensitivity to hot/cold foods, difficulty biting into apples and chewing meats, engaging in 2 hours of aerobics daily, and daily intake of energy/sports drinks. The nurse inspects Brianna's oral cavity. Brianna's teeth look fragile, with notching of four upper/lower front teeth. Brianna is referred to a psychiatric-mental health NP who treats patients with eating disorders. The nurse also refers Brianna to a local dentist who specializes in repairing dental erosion.


Case study #2


Barry, 52, had untreated GERD for 2 years. Barry tells the nurse that acid reflux wakes him at night, and he brushes his teeth to remove the sour taste. Lately, he's noticed severe tooth sensitivity/discoloration. The nurse sees that Barry's teeth have notches along the upper and lower front teeth. The nurse advises Barry about the dangers of tooth brushing during "the vulnerable hour." She instructs him to avoid foods and beverages that trigger his symptoms and to remain upright after eating to keep acid from reaching his mouth. The nurse also teaches Barry that drinking milk after the final meal of the day can neutralize gastric acids.


Case study #3


Doreen, 48, is undergoing chemotherapy with I.V. cisplatin and 5 FU, along with daily radiation. Despite antiemetics, treatments have led to high-volume (>300 cc/episode), high-frequency (>4 times/day) vomiting for the past 3 months. At the onset of chemotherapy-induced vomiting, the oncology nurse advises Doreen to rinse with warm saltwater after an episode of vomiting and wait 60 minutes before gently brushing her teeth with an ultrasoft toothbrush to prevent dental erosion.


Key points

Before dental erosion occurs

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* Identify high-risk groups






hyperemesis gravidarum




cannabinoid hyperemesis syndrome


limited upper extremity mobility and dexterity


dry mouth


* Educate patients who are starting drugs that cause dry mouth on how to prevent dental erosion


* Premedicate to prevent vomiting during chemotherapy



Signs dental erosion has started


* Tooth discoloration


* Transparency around the edges of the tooth


* Front top/bottom teeth become notched


* Patient reports pain with hot and/or cold foods and beverages


* Patient reports pain with eating and chewing



Once dental erosion has started


* Educate about waiting 60 minutes before brushing teeth after vomiting and using an ultrasoft toothbrush once it's safe to resume brushing


* Recommend rinsing with warm saltwater after vomiting


* Refer to a dentist for evaluation and monitoring of progressing dental erosion



Lifestyle changes


* Encourage eliminating acidic food and beverages


* Advise not to use teeth-whitening products


* Recommend using adaptive equipment or the aid of others if patient cannot move upper extremities



On the web

American Dental Association:

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World Health Organization:


INSTRUCTIONS Preventing dental erosion in at-risk patients



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