Sir, I was interested to read the article A personal perspective and update on erosive tooth wear - 10 years on: Part 1 - Diagnosis and prevention by D. Bartlett (BDJ 2016; 221: 167–171).

It was fascinating to see the photographs in the article. Most of the erosion in the photographs has occurred in caries prone sites such as cervical caries and cusp tip caries. If the erosion is due to acidic drinks and acids in the environment of the teeth then whole teeth should be affected.

The photographs also show the upper teeth are affected more than the lower teeth. If acids in the environment are the cause of erosion then the lower teeth should be affected more; because of gravity acids should be more concentrated in the floor of the mouth.

It could well be possible that enamel softened by initial carious lesion may be more susceptible to the effects of erosion, abrasion and attrition.

L. K. Bandlish mentioned in his book, Colour atlas of a new concept of enamel caries in 1987 that enamel caries occurs where there is least attrition and least plaque. This meant that the enamel caries starts at the edge of the plaque where the plaque is at its thinnest. Most of the enamel caries starts at the convexities of enamel because the edge of plaque is located at the convexities of enamel. It so happens that the enamel is at its thickest at the convexities including the cusp tips. It is well known that acid attack is clearly ahead of bacterial front because there are no bacteria in the carious lesion before it cavitates. The bulk of enamel caries starts at the clean contact area which may be at its cervical border. Root caries is an entirely different disease and should not be mixed with enamel caries.

Over brushing in an effort to remove the plaque, reduce the decay and whiten the teeth leaves very little plaque. It may also be lack of plaque which leads to erosion, abrasion and attrition. Plaque like perspiration and inflammation is a defence mechanism of the body. The human mouth is always inhabited with bacteria and the amount of plaque has no relationship to caries.

1. London