Clinical practice guidelines on the management of acid erosion

The purpose of developing clinical practice guidelines on the management of acid erosion was to provide evidence-based recommendations for the diagnosis and treatment of acid erosion to supplement the dentist's professional judgment and the patient's needs. A meta-analysis and systematic review of the literature was conducted to answer the following research questions: (1) What indices provide for the effective diagnosis of acid erosion? (2) What treatment modalities provide for the effective treatment of acid erosion? A preliminary search of the literature returned 30 publications. Application of exclusion criteria - publications without original research and those lacking necessary statistical data were excluded - reduced the number of publications to 4 studies addressing the treatment question only. A secondary search yielded an additional 22 studies on treatment and 7 studies on diagnosis, all of which were laboratory studies. Publications retrieved from both searches were subjected to the 2 exclusion criteria as well as 5 inclusion criteria: more than 1 study examining a diagnostic tool or treatment agent, publication between 2009 and 2015, use of human teeth, information on concentration and amounts of therapeutic agents (for treatment studies), and statistical information for computation of coefficient of variance. Application of all criteria reduced the total number of usable publications to 4 studies on diagnosis and 9 studies on treatment. A meta-analysis of these studies used coefficients of variation by outcome as a way of quantifying information that was most likely to be usable as practice recommendations. Basic Erosive Wear Examination (BEWE) and optical coherence tomography (OCT) were found to be valid indices for diagnoses of erosive qualities. However, given the impracticality of OCT in the dental practice setting, BEWE was found to be the recommended index for the diagnosis of acid erosion in the dental practice setting. The 4 studies aimed at reducing enamel surface loss, reducing tissue loss, or increasing microhardness were found to have the most repeatable findings in the dental practice. The recommended treatment options for the dental practice, deduced from the laboratory studies, included stabilized stannous fluoride (slurry), stabilized stannous fluoride in combination with chitosan, prescription and over-the-counter concentrations of sodium fluoride (applied as slurry or slurry plus brushing), casein phosphopeptide-amorphous calcium phosphate paste, and 1.23% acidulated phosphate fluoride gel (applicator or brush application alone or with the accompaniment of pulsed neodymium-doped yttrium-aluminum-garnet laser). However, weight could not be accorded to these recommendations, as the findings of the studies could not be validated (or invalidated) by the findings of other studies within the included literature. Additionally, there were no clinical studies. Findings from in vitro models may be heavily influenced by study design, and study design was not evaluated as part of this meta-analysis, increasing the potential for bias. Additional research, including broader inclusion criteria, clinical studies, and evaluation of preventive interventions, is strongly recommended.